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Full text of "A treatise on diseases of the joints"

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THIS IJOOK ISTJHEGIFTOF 




CORNELL UNIVERSITY LIBRARY 



3 1924 104 224 732 




The original of this book is in 
the Cornell University Library. 

There are no known copyright restrictions in 
the United States on the use of the text. 



http://archive.org/details/cu31924104224732 



A TREATISE 



DISEASES OF THE JOINTS. 



March. 



A TREATISE 



ON 



DISEASES OF THE JOINTS 



RICHARD BARWELL, F.R.C.S., 

SENIOR SURGEON AND LECTURER ON SURGERY, CHARING CROSS HOSPITAL 



IIIuBiiaftb bg ^anurous ffittgrabings on 38oob 



SECOND EDITION 

REVISED AND MUCH ENLARGED 



NEW YORK 

WILLIAM WOOD & COMPANY 

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(861 



PREFACE TO SECOND EDITION. 



For some considerable time a Second Edition of my Treatise 
on Diseases of the Joints has been called for, and indeed, 
though never ceasing to study clinically and anatomically 
these affections, I began twelve years ago more especially to 
prepare my materials and myself for its production. Soon 
after 1861, whether the appearance of my First Edition was 
the stimulus, or merely fortuitously I know not, many excel- 
lent essays were published, and much careful investigation 
was undertaken here, in America, in Germany, and in France ; 
moreover, personal experience and research had provided me 
with a quantity of material. Hence, it became more and 
more evident as time went on that the Second Edition must 
undergo such enlargement and revision, that it appeared to 
me better to re-write the whole book. In its present form, 
therefore, the Treatise contains but a few words here and 
there of the First Edition. 

Nevertheless, the lines of 'construction are, to a consider- 
able, extent, the same; especially does experience show me, 
that the distinction which I at first drew, but which has been 
much criticised, between such maladies as commence in the 
synovial membrane and such as begin in the bones, must be 
maintained by him who would afford to his patients the full 



VI PREFACE TO THE SECOND EDITION. 

' benefit of a treatment founded on accurate and scientific .diag- 
nosis. 

Plainly may it be foreseen, that the doctrine of certain 
absorptive diseases discussed in Chapter IV; will meet with 
criticism, even with scepticism. I, myself, long doubted if 
such pathological sequence stood in the true relationship of 
cause and effect ; but, even while thus hesitating, several per- 
fectly characteristic cases, following each other in rapid suc- 
cession, left no room for ambiguity. 

The volume should, if possible, have been smaller in bulk ; 
but even as it is, much that might have been said has been 
omitted. I hope, however, that the book may not be found 
either tedious or wearisome ; if only it meet with a reception 
as favorable as that of the earlier edition, my aspirations as 
to its fate will be amply fulfilled. 



Richard Baewell. 



32 George Street, Hanover Square, 
London. TV. 

February, 1881. 



CONTENTS, 



CHAPTER I. 

Physiological Anatomy. 

PAGES 

Constituents — Classification of joints — Histology of bone — Articular lamella — Car- 
tilage — Development of limbs — Of joints— Genesis of synovial membrane — 
Peri-articular tissues and ligaments— Vascular and nervous supply 1-22 



CHAPTER H 

Acute Synovitis. 
Pathology : Morbid anatomy — Changes in secretion — Leucocytes in synovia, — 
Purulent synovitis — Dry synovitis. Symptoms : Not constitutional — At dif- 
ferent joints. Treatment : Best — Counter-irritants — Depletives— Punc- 
ture 23-45 

CHAPTER HL 

Suppurative Synovitis. 

Pathology: Cell-broods — Cell-emigration — Fringe hypertrophy — Rupture of sy- 
novial membrane — Shedding of cartilage — Adjacent and neighboring abscess-i- 
Malpostures —Dislocations. Symptoms : Rigors— Pyrexia — Pain — Fixity — 
Distortion — Prognosis. Treatment : Of joint-wound — Purges— Depletives 
— Narcotics — Incisions — Question of amputation 46-63 

CHAPTER IV. 

Pyemic Joint Disease and other Absorption Diseases. 

Pathology : Venous origin of pyaemia — Microzymes — Secondary abscess — Ure- 
thral and utero- vaginal pyaemia. Symptoms : Of pyaemia— Urethral — Ante- 
partum— Post-partum — Catamenial — Typhoid fever and exanthematous syno- 
vitis. Treatment : Quinine — Sulpho-carbolate of soda — Parenchymatous 
carbolic injections — Examples 63-93 



V1U CONTENTS. 

CHAPTEB V. 

Strumous Synovitis. 

PAGE* 

Pathology : Struma — Granulation-tissue - Invasion of neighborhood — Ligaments 
— Inflammation and ulceration of cartilage of bone — Reparative processes— 
Anchylosis— Three sorts of abscesses — Malpostures — Luxations — Contraction 
and contracture of muscles. Symptoms : Types of struma — 1st stage : Com- 
mencement of disease — Form of swelling — Locality of pain — 2d stage : 
Starting-pain and bone-invasion — 3d stage : Repair or destruction — Forms of 
luxation. Treatment : General— Rest— Posture — Extension — Counter-irri- 
tation — Parenchymatous injections — Movement — Actual cautery — Manage- 
ment of abscess 94-137 



CHAPTER VI. 

Subacute Rheumatic Synovitis. 

Pathology : Mono- and poly-articular organizing tendency — Thickening of tis- 
sues — Relationship to hydarthrosis. Symptoms : Origin — Lithic diathesis — 
Peculiar shape — Silken crepitus. Treatment : General — Medicines and diet 
— Asthenic and sthenic form — Rest — Position — Counter-irritants — Oleate of 
mercury— Blisters — Puncture 138-156 



CHAPTER VH. 

Syphilitic and Gouty. 

Of syphilitic — Two forms — Difficulty of Diagnosis — Combination with other syphi- 
litic symptoms which guide treatment. Pathology : Gout —Lithic diathesis 
— Lithate of soda — Deposit in fibrous tissues — Cartilage — Bone. Symptoms : 
Tonic and atonic — Sort of pain — Influence ofjead —Changes of form. Treat- 
ment : Colchicnm — Atropine — Digitalis — Iodine — Alkalies — Diet — Natural 
waters and baths 157-164 



CHAPTER Vm 

Hydarthrosis or Hydrops Articuli. 

Pathology: Distinctions — Different forms of hypertrophied fringes — Peculiar 
thickening — Not oedema — Multiple false bodies. Symptoms : At different 
joints — Stretching of ligaments — Subsequent looseness — To distinguish dif- 
ferent forms. Treatment : By evacuation — Incision — Injections 165-179 



CONTENTS. IX 

CHAPTEE IX. 
Movable Bodies in Joints. 

PAGBS 

Pathology : History — Constituents — Genesis — Traumatism. Symptoms : First 
invasion — Sudden seizure — Acute synovitis — Hydarthrus — Attached or non- 
attached. Treatment : Fixation by pins and bandages — Subcutaneous and 
free excision — Statistics — Mode of operating — Cases and specimens 180-196 



DISEASES COMMENCING IN THE BONES. 

CHAPTER X. 

Acute Ostitis. 

PATHOLOGY : Commences in or near epiphysis — Traumatism — Effusion — Intra-os- 
seous pressure — Diastasis— Mode of joint-affection — Abscess of soft parts. 
Symptoms : Rigors — Pyrexia— Pain — Dusky redness — Great tumefaction — 
Distortions of diastasis— Pyaemia. Treatment : By excision or expective — 
Strong tincture of iodine — Support — Management of diastasis 197-21d 

CHAPTEE XI. 

Chronic Ostitis. 

Pathology : Macroscopic inflamed bone —Enlargement of Haversian canals — 
Mechanism of bone-absorption — Different views — Enlargement of lacunas — 
Fatty ostitis — Infantile softening and induration — Ostitis of immature epi- 
physis. Symptoms : Sort of pain and swelling — Early starting-pain — Table 
of diagnosis — Necrosis and caries — Diagnosis— Mode of joint-implication — Ca- 
ries necrotica — Diastasis — Shortening — Occasional lengthening — Mode of re- 
pair. Treatment : General — Aetual cautery — Extension — Splint — Paracen- 
tesis ossium — Sequestra removed 214-251 

CHAPTER XH. 

Arthritis Deformans. 

Pathology: Nomenclature — History of — State of various tissues. Bones: 
Form-changes by atrophy and hypertrophy — Osteophytes— Marginal hyper- 
plasia — Porcelanous deposit. Symptoms : Poly- and mono-articular forms — 
Sorts of pain and swelling — Synovial crepitus — Changes at different joints. 
Treatment : Tonic — Arsenic: — Mercury — Local baths— Natural, sulphur, and 
other waters 252-266 



X CONTENTS. 

CHAPTER XITL 

Inflammation and Degeneration of Cartilage. 

PAGES 

No joint disease beginning in cartilage — Chondritis — Inflammatory fibrillation — 
Shedding— Degenerative fibrillization of— Effects of immobility on cartilage 
— Ecchondrosis — Hypertrophy — Atrophy 267-273 

CHAPTER XTV. 

Hip-Joint Disease. 

Pathology : Frequent origin in epiphysis or junction — Morbid anatomy — Acetab- 
ular hip disease — Intra-pelvic abscess — Pressure effects— Knee-pain — Length- 
ening, shortening, and flexion explained — Abscess — Place of pointing — Luxa- 
tion often slow — Diastasis — Hip disease and phimosis. Symptoms : 1st stage : 
Modes of limping— Of pain and tenderness — Fixity of thigh — 2d stage : Diag- 
nosis of lengthening, shortening, and of flexion — Interpretation of knee-pain 
— Qf swellings— Diagnostic table — 3d stage: Shortening abscess —Caries — 
Signs of recovery. Treatment : Early — Splints— Extension — Counter-irri- 
tation — Puncture of joint— Intra- pelvic abscess— Dangers — Management. .274-316 

CHAPTER XV. 

Sacro-iliac Disease. 

Pathology : Spinal and joint form — Caries — Necrosis — Abscess. Symptoms : 
Diagnosis from Morbus coxae — Examination by movement — By pressure — By 
swelling — Search for place of caries. Treatment : Best — Counter-irritants 
—Opening abscess — Search for sequestra — Trephine over the joint — Mechan- 
ical support 317-323 

CHAPTER XVI. 

Affections of Sheaths and Btnts^i. 

Bursa? — Their localities— Acute and chronic inflammation — Housemaid's knee — 
Deep bursas — Sheaths — Palmar sprains — Painful crepitation — Dropsy — Melon- 
seed bodies — Ganglia, anatomy of —Cysts in popliteal space 323-338 

CHAPTER XVH. 

Hysteric Pseudo-Disease of Joints. 

Pathology : Hysteria not coexistent with the fit— Phases at different stageB— 
Prognosis. Symptoms : Peculiarity of pain— Absence of inflammation— Usu- 
al localities. Treatment : Partly mental— Uterine states — General hygiene 
— Coccydynia— Operation for 339-350 



CONTENTS. X3 

CHAPTER XVm 

Restoration of Crippled Joints. 

PAGES 

Causes of joint stiffness — Diagnosis in various joints — Behavior of muscles— Re- 
sults of certain diseases — Sudden force — Division of tendons, etc. — Manipula- 
tion at different joints — Caution to avoid subluxation — After-treatment for 
attainment of different aims — True anchylosis — Osteotomy — Hip — Knee — El- 
bow — Nature's modelling — Care in selecting cases, etc 351-382 

CHAPTER XIX. 

Genu Varum and Valgum. 

Anatomy of — Selection of cases — Separating internal condyle — Division of femur 
— Also, when necessary, of leg bonea — Mode of opeiation — Occasional subsid- 
iary twists of the limbs 383-389 

CHAPTER XX. 

The Removal op Diseased Joints. 

Circumstances which justify removal — Amputation and excision, and causes of 
preference for each — Comparative safety of excision — Selection of cases — 
Points to be observed in excision — Reparative processes after excision — Ten- 
dencies of union at different joints — Statistics, operation, results, and other 
information concerning — Excision of the shoulder — Elbow — Wrist — Parts 
about the hand — Hip, knee, and ankle 390-447 



APPENDIX TO CHAPTER XTV. 
On the Alleged Occurkence op Real Lengthening 448-454 



A SHORT LIST OP FORMULAE 455 

INDEX * 4 s9 



LIST OF ILLUSTRATIONS. 



FIOUR* pAO , 

1. I'ancelli and Articular Lamella, magnified 10 diameters 4 

2. Ditto, magnified 100 diameters 4 

3. Articular Lamella, highly magnified , 5 

4. Section of Human Cartilage, magnified 700 diameters 9 

5. Genesis of Synovial Membrane (diagrammatic) 10 

6. Section at Junction of Synovial Membrane and Cartilage 11 

7. Section of Strumous Ulcer in Cartilage 101 

8; Section of Cartilage changing into Fibrous Tissue '. 101 

9. Upper Surface of Tibia : Ulceration of Cartilages 103 

10. Strumous Synovitis of Knee (early stage) 109 

11. " " " (a little later) 110 

13. " " Elbow .* Ill 

13. " " Ankle Ill 

14. Pathological Dislocation of Tibia (outward) 117 

15. Strumous Synovitis of Ankle (somewhat advanced) 130 

16. " " Elbow (advanced) 135 

17. Hydarthrus of Knee 167 

18. Hypertrophied Fringes, seen under Water 168 

19. Hydarthrus of Knee (Enlargement of Subcrureal Pouch) 171 

20. Bony Loose Body from Knee (natural size) 191 

21. Loose Cartilage from Knee 193 

22. Lipomatous Loose Bodies from Knee 194 

23. Ostitis, slightly magnified, and natural size (Howship) 216 

24. Transverse Section of Femur of Rabbit (normal) 219 

25. " " " (inflamed) 220 

26. A Lamina from Human Tibia (normal) 220 

27. " " (inflamed) 221 

28 Upper End of Tibia ; Caries Necrotica 221 ' 

29. Articular Ostitis (Internal Condyle) 228 

30. Ostitis of Astragalus 228 

30a. Ostitis of Condyles (Posterior Subluxation) 233 

31. Caries Necrotica of Tibia (Diastasis) 235 



XIV LIST OP ILLUSTRATIONS. 

FAQS 
HGUBE 

32. Ostitis of Tibial Tuberosity, with Shortening aon 

33. Recovery after Ostitis of Tibia 338 

24.1 

34. Extension Splint 

947 

35. Ostitis of Tibia **' 

36. " CarpalBones 247 

37. " InnerCondyle 249 

38. " Head of Humerus 350 

39. Arthritis Deformans, Marginal Hyperplasia 256 

40. Marginal Hyperplasia of Head, Femur encroaching on Neck 257 . 

41. Hand in Early Arthritis Deformans 2t ' 3 

42. Hand in Late " " 263 

43. Upper End of Femur -Still-born Child 275 

44. Diagram of Relations of Diaphysis. Epiphysis, Apophyses, and Synovial Mem- 

brane at Upper End of Femur 275 

45. Femoral Hip Disease, beginning at Epiphysal Junction 276 

46. " " Result of Epiphysitis 277 

47. Shedding of Cartilage, Epiphysitis of Head of Femur 278 

48. Acetabular Hip Disease, Intra-pelvic abscess 279 

49. Caries of Acetabulum and Head of Femur, Result of Upward Pressure 281 

50. Abduction of Femur as causing Lengthening (diagram) 281 

51. Lengthening w^th Obliquity of Pelvis (diagram) 384 

52. Adduction of Femur as causing Shortening (diagram) , 284 

53. Flexion (diagram) 286 

54. Flexion as causing Pelvic Malposture and Lordosis (diagram) 286 

55. Semicircular Impression of Margin of Acetabulum produced by Partial Luxa- 

tion 287 

56. Left Hip Disease — Lengthening 296 

57. " Shortening 297 

58. '* Flexion 298 

59. Flexion in Recumbency — Thigh raised 299 

60. " " Thigh Depressed, Masked by Lordosis 299 

61. Infantile Hip Disease— Third stage 304 

62. Old Hip Disease— Shortening ' 305 

63. Extension Splint for Hip 312 

64. Enlarged Bursa Patellae — Knee flexed 325 

65. Double Housemaid's Knee — Knee extended 326 

66. Synostosis at Angle of 80 degrees 372 

67. Result of Osteotomy '. 373 

68. Anchylosis of Knee 381 

69. Result of First Operation 381 

- 70. " Second Operation 381 

71. Bow-legs 383 

72. ' ' Straightened by Operation 384 

73. Bony Acatomy of Genu Valgum 385 

74. Typical Case of " 386 



LIST OF ILLUSTRATIONS. XV 

HOUSE PAQE 

75. Straightened by Operation^ 386 

76. Genu Valgum, with Subsidiary Curves 388 

77. Straightened by Operation 388 

78. After Excision of First Joint of Thumb 421 

79. Twelve years after Hip-Excision 424 

80. Four Months after Hip-Excision (Timothy D. ) 427 

81. Condition of Parts (Timothy D.), the Femur turned out of Cavity 428 

82. " " " " in situ 428 

• 83. After Hip-Joint Excision — perfect result 433 

84. Same Case with Thigh Flexed 433 

85. Shortening after Knee-Exc sion (Pemberton) 437 

86. Splint for After-treatment of Knee-Excision 438 

87. Knee-Excision. Patella Left 439 

88. Knee-Excision, Patella Kemoved 439 

89. Unusual Condition after Knee-Excision 441 

90. Two j ears after Knee-Excision , 443 

91. After Excision of the Ankle 446 



A TREATISE 

ON 

DISEASES OF THE JOINTS. 



CHAPTER -L 

PATHOLOGICAL ANATOMY. 

It is more than probable that my readers are well acquainted with the 
anatomy of joints ; yet I offer no apology for beginning this treatise with 
an account of the form and minute structure of articulations, and for these 
reasons : if he who takes up this volume have not followed pretty closely 
the most recent microscopical studies, he will not know what in this chap- 
ter I shall hope to explain ; while if he have pursued those inquiries, he 
must be aware that certain considerable differences of view exist. Unless 
my anatomical opinions are postulated and defined, the pathological con- 
siderations to be encountered hereafter must, without some foundation, bo 
mere castles in the air. 

The diarthrodial or movable joint will almost exclusively occupy our 
attention, but one form of the synarthrodial, viz., amphiarthrosis, is not 
strictly immovable, and one such articulation must for a little space claim 
our notice. Yet, although the amphiarthrosis is not in our sense a joint, the 
fibres and fibro-cartilages which separate, and at the same time unite the 
bones, permit, by their flexibility, a certain mobility, facilitated in another 
part by the interposition of a synovial bursa, not, be it distinguished, a syno- 
vial membrane. 

To our idea of a diarthrodial joint are necessary a distinct cavity lying 
between and separating the bones of the articulation, also at least two 
pieces of cartilage interposed between those bones ; each piece of cartilage 
lining the end of each bone is not continuous, but in contact, with the 
other. The gliding, rolling, or twisting movement must take place between 
these cartilaginous surfaces, kept moist by a secreting membrane, which 
closes in the cavity of the joint. The essential constituents then of a diar- 
throdial joint are : 

1st. — The bones, which are in apposition, but separated from each other 
by a cavity. 

2d. — The cartilages of incrustation. 
3d. — The synovial membrane. 
1 



2 DISEASES OF THE JOINTS. 

But besides these axe : 

4th. — Ligaments binding the bones together. 
5th. — Frequently an interarticular fibro-cartilage. 

The bones which enter into the formation of a joint may be twp or 
more.. In the scapulo-humeral articulation is an instance of two bones 
jointed together ; in the elbow of three, but two of these only are essen- 
tial to the joint as a hinge, the other being added for purposes of its own 
(if it may be so expressed). In the ankle are three bones essential to 
the joint, two forming a socket, into which the head of the third is re- 
ceived. The hip-joint is composed in early life of four bones, but later it 
abrogates this peculiarity, the three which formed the socket becoming 
united into one. The shape of the articulating surfaces of the bones de- 
termines the species and form of the joint. Descriptive anatomy divides 
them into four classes : 

1st. — Arthrodia, or flat-joint. 

2d. — Enarthrosis, or ball-and-socket-joint. 

3d. — Ginglymus, or hinge- joint. 

4th. — Diarthrosis, or pivot-joint. 

The different species of movement which these forms of articulation 
permit have been the subject of more or less elaborate treatises ; but the 
shape of the joint surface has no influence on the action of its diseases. 
Although, then, for purposes of diagnosis and of treatment, every surgeon 
must be well acquainted with the form of the surfaces, as with the sort and 
extent of motion normally permitted by each articulation, yet it does not 
appear desirable to describe here what may be found in eveiy adequate 
anatomical work. 1 

It is not necessary to give here an account of the ossifying process in 
cartilage, nor is it my desire to append an unnecessary and therefore pe- 
dantic description of bone-tissue ; but, in order that the pathology of cer- 
tain joint diseases may be regarded from the same point of sight as is taken 
in this work, it is desirable that the author's views of osseous structure 
should be clearly expounded. Bone is generally described as a compound 
of cartilage and phosphate of lime, plentifully supplied with vessels, among 
which a large number of branched cells are arranged in a more or less defi- 
nite order. Let us describe the structure in the same language differently 
placed, and say : Bone consists of a number of cells (connective-tissue 
corpuscles) whose interstices (intercellular spaces) are occupied by a com- 
pound of cartilage and phosphate of lime, and among which vessels pass in 
a certain definite relation. By adopting this method of description the 



' Some controversy has taken place concerning the forces which daring develop- 
ment determine the shape of articular surfaces ; some writers hold that these are pri- 
marily fixed, and that the muscles are afterward so attached as to impress on the bones 
such movements as are consonant with the form of the joint. Others believe that the 
mode of muscular attachment, and the motions so inaugurated, mould the bone ex- 
tremities into the shape's we knowthem by. To me this appears something like the 
verbal puzzle as to which had the priority in creation, the egg or the hen. The pro- 
cess of fissuration in the limb cartilages, and the formation of muscle, take place in the 
foetus at the Bame time, from the sixth to the eighth week ; but it is hardly possible 
to conceive that at that date a limb, as the thigh or arm, could enjoy such extended 
movement as to mould, press, or grind into form, a globular head and a round cavity ■ 
or that the hand would be so dexterously and busily employed as to polish out of a 
formless matrix so perfect a circle and pivot as the head of the radius. 



PATHOLOGICAL ANATOMY. d 

different elements of which bone is composed are reduced to their proper 
relation— first the cells, lying in cavities (cell-spaces), with many branches 
or canaliculi, then the intercellular substance, and then the vascular sup- 
ply. The cells of the bone are contained in the lacunae, the cell-walls line 
the spaces, and the nuclei may be seen within them. Messrs. Tomes and 
Campbell de Morgan state that they " have had no difficulty in finding the 
nuclei in recent bone without the aid of chemical treatment. If a small 
fragment be taken from the spongy portion of a fr-esh bone, and freed from 
adherent fat, the nuclei may be seen as small rounded bodies attached to 
the walls of the lacunas." ' Other observers, quoted by the above-named 
authorities, also believe in the persistence of the nuclei ; viz., Goodsir, 
Schwann, Krause, Kohlrausch, Heischmann, Griinther, Donders, and more 
recently a host of others, among whom Virchow and Neumann may be 
named. I possess many specimens, in which the nuclei are very evident. 
The lacunae, and the cells contained in them, have not mere even, round, 
or oval walls, but branch out into a great number of fine processes, called 
by Todd and Bowman canaliculi ; they are actual spaces in the hard tissue, 
containing a membranous matter, but whether the membrane itself be 
really tubular is doubtful. A section through the dense structure of a long 
bone, the humerus for instance, shows the following arrangement of parts. 
The whole mass of the bone is disposed round an axis, so that the section 
is ring-shaped ; in the outer and inner edge of the section the disposition 
will be shortly described. Between these two parts the cells are seen 
usually to surround certain vessels in canals called Haversian, that run for 
the most part in the direction of the axis of the bone — the whole arrange- 
ment, canal and surrounding cells, is called an Haversian system — certain 
parts which fill up the interstices between these circles are named by 
Kolliker ("Mikroskopische Anatomie," p. 292) Interstitial Laminae ; by 
Quekett they are more happily termed " Haversian Interspaces " (" Histo- 
logical Catalogue of the Museum of the College of Surgeons "). In the inner 
and outer layers of bone, or Circumferential Laminae, the cells are arranged 
round the axis of the bone ; most of them are of the ordinary size and 
shape of the lacunae in the Haversian systems ; but there are among them 
certain longer cells, some of which run at right angles,' others, seen on 
longitudinal section, parallel to the axis ; thus there are in the layer next 
the medullary cavity, and next the periosteum, two sets of long cells, which 
run at right angles to each other. I believe these are intended for the 
rapid absorption and disintegration of both these strata. 

Thus it will be understood that bone is to be considered simply as a 
connective, an areolar tissue, the ground substance of which has been sat- 
urated with lime-salts. In it are all the elements of that tissue as they may 
be found surrounding a vessel. There is the space in which the little vas- 
cular branch lies (Haversian canal); around it are arranged connective- 
tissue corpuscles (bone-cells) lying in cell-spaces (lacunae) and provide/! 
with branches (canaliculi). But these parts, which represent the yellow 
element of areolar tissue, do not stand alone. In the lamellae a little care 
and skill will bring into view the fibrous and often wavy form of the inti- 
mate bone-tissue itself, which is evidently calcified white areolar struc- 
ture ; for many occurrences in the process of ossification show that the 

1 Observations on the Structure and Development of Bone : Philosophical Trans- 
actions, 1853, p. 117. 

'-' Messrs. Tomes and De Morgan On the Development and Structure of Bone : 
Philosophical Transactions. 1853. 



4 DISEASES OE THE JOINTS. 

primordial cartilage becomes quite changed by peculiar cell arrangement 
. and proliferation previous to the deposit of lime. I hold that it is of great 
importance to the full comprehension of all bone disease, that its physi- 
ological anatomy and constitution should be thus considered. 1 

But it is of course to be noticed that no joint surface lies immediately 
upon hard solid bone, such as composes a shaft, but upon a reticulated or 
cancellated structure, i.e., upon the epiphysal ends of long, or as at the 
carpus and tarsus upon short bones. 

As the shaft of a newly ossified bone is solid, i.e., has no central med- 
ullary cavity, so the epiphyses of long bones and the mass of short bones 
are at first without that subdivided cavernous hollow, which we know as 
the cancellous structure. The formation of these little inter-communica- 
ting cavities is ,due to a process of absorption, which commences in the 
middle of the nucleus as a secondary process, and while yet it is increasing 
centrifugally. Thus, however hard and solid the texture of a bone may be, 
the joint ends are always spongy (short bones are entirely so), that is, they 
consist of an outer cortex, enclosing a number of cancelli, which contain 
medulla, divided from each other by thin osseous plates, lamellae. The 
lateral cortex, i.e., those walls of the structure which do not look toward 





Fig. 1.— Cancelli and articular lamella from Fig. 2— Cancelli and articular lamella 

lower end of human tibia, magnified about 10 from lower end of human tibia, magnified 

diameters. 100 diameters. 

the joint cavity, are very thin, and the lacuna! arrangement is in general 
irregular, except where a vessel passing to the interior forms an Haversian 
canal and concentric laminae. The lamellae which branch from its internal 
surface, enclose the caneelh, and permeate the whole area of the short bone 
or epiphysis, are very variable in size and strength in different parts, in 
different persons, and at different ages ; from .03 to .06 of an inch may be 
taken as a fair average of their thickness, the cavities about .6 to .3 in length 
and breadth. Each cavity is incompletely surrounded by lamellae, there 
being open communications throughout from one to another, whereby 
blood-vessels freely pass and anastomose ; these cancelli, which are lined by 
a fine membrane and contain medulla, are in mature long bones but a pro- 
longation with infinite subdivisions of the central medullary cavity. The 
lamellae appear at first sight to be arranged in an arbitrary, fortuitous 
manner ; but examination of sections from dry specimens shows that they 
are so built up as to afford the greatest mechanical support to that part of 
the outer crust where most pressure will be exerted, especially therefore 
to that surface forming the joint ; under that surface the cancelli are as a 
rule smaller and the lamellse thicker. 



1 Many phenomena, some of which will shortly be noticed, show how often and 
how easily cartilage becomes thus metamorphosed into a more or less perfect areolar 
tissue. Indeed, although the primordial cartilaginous skeleton is in subsequent de- 
velopment changed into bone, yet it undergoes a previous modification into a fibrous 
structure. This is described in all adequate works on histology, and we shall shortly 
meet with a brilliant example of such metamorphosis. 



PATHOLOGICAL ANATOMY. a 

The plate of bone which lies next to the articular cartilage is very pe- 
culiar ; it is applied to the cancellous structure, but never roofs in a cavity. 
However nearly such cavity may approach the articular lamella, a plate of 
true bone always separates the one from the other. On section it is seen 
to consist of a very hard layer of irregular or serrated edge (in section), and 
also irregular at the part next the cancelli. It possesses no true bone 
lacunse with canaliculi, but simply blots (in this view black and opaque), 
oval in form, whose long axes are perpendicular to the surface ; they are 
arranged linearly in the same sense, or rather the general trend of their ar- 
rangement is at right angles to the surfaces ; they are of the same size and 
outline as cartilage corpuscles. Except indeed for some difference in re- 
fraction and for its. hardness, this lamella is, like the deeper layer of carti- 
lage, altered by the deposition of lime-salts. Yet changed not only thus, 
for it is on examination with a high power (Hartnack 6) evident that fibril- 
lation has preceded calcification, evidenced by very fine wavy striation in a 
direction perpendicular to the surface. 1 

The appearance of these lines is the more noteworthy since the laminar 
strata in the bone immediately underlying this layer is in a contrary direc- 
tion, viz., parallel to the surface. The lines are not evenly distributed 
throughout, but are, as it were, gath- 
ered into bundles, which appear to 
correspond to the position of a black 
corpuscle. They are most readily 
perceptible in specimens that have 
been ground thin, yet are also quite 
distinct in those that have been de- 
calcified. If the specimen be very 
much soaked in absolute alcohol and 
mounted in dammar, the varnish 
runs into the wavy lines, and is apt 

to obscure them. The lamella is Fio. 3.— The articular lamella, highly magnified. 

cartilage which has become fibril- 

lated and received a deposit of lime, but has not become true bone be- 
cause it lies beyond the limit of the ossifying force ; hence decalcification 
causes the spots, which in sections ground thin appear as black spots, to 
regain all the characters of normal cartilage-corpuscles. This layer is 
rather a part of the encrusting cartilage than of the bone, and pathological 
conditions will hereafter show that in all changes it sides with, and shares 
the fate of, the former structure. 

The articulations, lying at an adult age on the ends of long bones, are 
in early life not quite thus placed, since at that period the joint ends are 
separated from the shafts. % At a very early age, therefore, the articulation 
is not formed by bone at all, but by two pieces of cartilage, and it is not 
until babyhood has been left behind that there is any true articular carti- 
lage, or any such structures as have just been described. An articular car- 
tilage can only be said to exist when ossification of the epiphysis is com- 
plete. Yet long after this period, which varies in different localities, the 
epiphysal end of the bone remains separated from .the diaphysis by a disk 
(in section a line) of cartilage. At the junction of the shaft with the epi- 
physal line that addition to the length of the bones, on which increase of 

1 In my former edition I described these as very fine tubules ; therein was the error. 
The markings are not tubes in the sense of continuous elongated hollows ; nevertheless 
they are, I believe, pores permitting the transmission. of fluid. 




C DISEASES OP THE JOINTS. 

stature depends, chiefly takes place, although on the other, the epiphysal 
side of this line, a certain amount of growth is going on. This plastic ac- 
tivity necessitates, and is accompanied by, considerable blood-supply, and 
vascular excitement, which under certain circumstances may overstep the 
limits of physiological and pass into pathological conditions.' While their 
growth is going on, the epiphysal end divided from the shaft is quite inde- 
pendent in its viiscular and nutrient supply— as independent of the diaphy- 
sis as one short bone of the carpus, for instance, is independent of the 
others ; no vessel penetrates the epiphysal disk from the one portion to the 
other. These two latter circumstances, the plastic activity and the epiphy- 
sal isolation, produce certain differences in the physiological and pathologi- 
cal status of these joints, before and after the period of union to the shaft. 
It is, therefore, important to know when that union takes place. 

The annexed table gives the ages at which in different bones the epi- 
physal nucleus appears, as also the period of union to the shaft. 



Humerus . 



Nucleus appears. Epiphysis unites. 
( Upper 2d year .20th year. 

" ( Lower - { TroSa, nth ItZ } 16ih or 17th ? eax - 

Eadius i TJ ^ er 6th year 17th,year. 

| Lower 2d year. 20th year. 

Ij. J Upper 10th year 17th year. 

} Lower 4th year. 20th year. 

^Zges^} • 3d to 5th year 20th year. 

Pelvis Y Cartilage about 14th year . . 17th or 18th year. 

Femur I Upper lst ? eax 18th y ear - 

( Lower 8 months (fetal). .21st to 24th year. 

rp ibia j Upper before birth .. 21st to 22d yea*. 

" ' " I Lower 2d year 18th year. 

Fibula i Upper 3d or 4th year 24th year 

" 1 Lower 2d year 21st year. 

Phalange's 8 '.'.'.'.". } 3d to 8th year. .19th to 21st year. 

The four inner metacarpal and metatarsal bones have distal, the outer, 
proximal epiphyses. All the phalanges have the epiphyses proximal— thus 
all the metacarpo-phalangeal joints, save that of the thumb, are on two 
epiphyses ; so at the foot all metatarso-phalangeal joints are doubly epiphy- 
sal except the hallux. 

Moreover, the relationship between the epiphysal disk and the capsule 
of the joint is a matter of great import in the interpretation and prognosis 
of certain diseases. At some articulations these two parts hardly come into 
relationship, at others a part, in some the whole, of the epiphysal line is 
included in the synovial membrane. The following list gives the inter- 
relation of these parts for different joints. 

The Shouldek. — The capsule with its synovial lining is attached above 
to the margin of the glenoid cavity, which is not an epiphysal bone, below 
to the anatomical neck of the humerus. The two, sometimes three, ossific 
nuclei which form the upper part of the humerus-head and tuberosities, 
unite at the age of five or six years, and thus form a simple epiphysal end. 
The line of junction between this and the shaft runs from the inner incur- 



PATHOLOGICAL ANATOMY. 7 

vation of the groove called anatomical neck outward and generally a little 
downward to a point a little below the lowest projection of the tuberosities. 
There is then but a little piece of the epiphysal junction on the internal 
aspect of the bone which hes within the synovial membrane or close to its 
attachment. 

The Elbow. — All three bones which form this joint have a very narrow 
epiphysal end (from above downward) ; hence it happens that all three lines 
of junction are within the synovial membrane. The activity of growth is 
not here so great as at some other joints. The epiphysal line of the olecra- 
non is so placed that only its anterior edge interests the joint cavity. 

The Wbist-Joint is somewhat complicated. A single synovial sac lines 
the surface of the radius and the distal surface of the ulnar interarticular 
cartilage ; the upper bones of the joint and also the scaphoid, semilunar 
and cuneiform, the lower constituents. This is the wrist-joint proper, but 
the adjacent synovial membranes must be remembered. One of these lines 
the radio-ulnar articulation, and the junction between the ulnar and its fi- 
bre-cartilage. Another lubricates the joint between the first and second 
row of tarsal bones and also the carpo-metacarpal joints. The radial and 
ulnar epiphysal junction are not included in the first-named synovial mem- 
brane. As an epiphysal has already been described as analogous in its iso- 
lated mode of nutrition to a short bone, we must remember that the simili- 
tude holds good on that point in regard to the carpal bones. Yet we must 
also remember that the growth of a long bone from its epiphysal end is very 
considerable, the plastic and vascular excitement very marked. The in- 
crease on the small carpal bones is much less, and the formative activity can 
hardly be compared to that which occurs at the ends of a growing long bone. 

The Hip-Joint. — At the time of birth the femur has no real neck, a mere 
constriction separates the head (large in proportion) from the trochanters. 
Along this groove the capsule and synovial membrane are attached. After 
the child has passed the first two or three weeks of life, this part of the 
skeleton begins to grow, a neck is formed from the shaft of the bone, to 
which also a considerable part of the head belongs. The ossification at 
this upper end runs in the form of a wedge upward, so that all the upper 
extremity of the diaphysis hes between the epiphysal part of the head and 
the apophysal centre for the great trochanter. All this part (including of 
course the head) is enclosed in the synovial membrane, and the necessary 
great hyperplasia and hypersemia is within the cavity of the hip-joint. Also 
one aspect of the Y-shaped cartilage of the immature acetabulum lies inside 
the synovial membrane.' 

At the Knee. — The anterior edge of the femoral epiphysis at the knee 
is the only junction within the joint-cavity. 

Ankle. — The synovial membrane of the ankle-joint does not come into 
relation with the epiphysal junction. 

That part of the epiphysis or of a short bone which remains unossified 
toward the joint-cavity is (p. 4) separated by a peculiar structure from the 
ordinary bone-tissue, and now becomes articular cartilage. It is not, as it 
has often been said to be, attached to the bone, but it is continuous with 
it : it is part of the same thing, one portion having received a deposit of 
lime, the other not having done so. It varies in thickness according to the 
shape of the surface, and always so that its form is an exaggeration of that 
of the bone : thus, if the osseous surface be concave, the cartilage is thick- 
est at its edges, so that it is more concave than the bone itself. If, on the 

1 For further remarks on this subject, see Chapter XIV. 



8 DISEASES OF THE JOINTS. 

contrary, we take a convex example, the cartilage will be found thinnest 
at the edges, so that the whole Shape is more convex than the osseous 
surface. 

Cartilage is a tough elastic material, of a semitransparent bluish ap- 
pearance, and easily cut with a knife. If boiled for several hours in water, 
more rapidly if in diluted acetic acid, or if treated cold in almost any strong 
acid, it is dissolved into a jelly, which Miiller called chondrin, and which 
differs very little from gelatine. If thin sections be made through the sub- 
stance of the cartilage and examined by a quarter-inch power, the whole 
substance will be f ound to be very translucent, and to have a finely, mottled 
or granular aspect ; and there will be seen in it a great many bodies of an 
oval form. Some confusion has arisen from these having been named car- 
tilage-cells. The truth is, that they are cavities in the hyaline substance, 
having no lining membrane, which contain from two to six nucleated cells. 
I propose to call throughout this treatise each body, i.e., cells and hollow, 
the cartilage-corpuscle, reserving the word cartilage-cell for each one of 
the bodies contained in the cavity. These cells may, under various forms 
of treatment, be made to shrivel ; when their enveloping membrane is de- 
tached from the walls of the cavity, is thrown into folds, the shrunken cells 
may be seen loose within the hollow. Luschka found this to follow the ad- 
dition of water ; Albert, continuous electric shocks. The cells in the cor- 
puscle not unfrequently, while near the attached surface, separate and cause 
a division by fissure of the hollow into new corpuscles, and the observer 
will find the arrangement of these bodies somewhat peculiar, for if he ex- 
amine a fine vertical section of any articular cartilage in any animal, he will 
see those cartilage-corpuscles which lie near the attached surface well de- 
veloped, and containing each from two to six nucleated cells, and near this 
surface not only do the cells in each corpuscle, but also these latter bodies, 
tend to arrange themselves perpendicularly to the surface ; and when a cor- 
puscle divides, it does so in the same direction. As the object is passed 
under the glass toward the free surface, he will be struck by a change in 
this respect ; the cells no longer remain in the hollow so constantly per- 
pendicular to one another, and as they divide, they do so as frequently hori- 
zontally as in any other direction ; at last the divisions and the groupings 
all tend strongly to the horizontal ; the cells themselves become separate, 
and are flattened in the same direction, till at last they become mere scales, 
three or four layers of which (Fig. 4), lying close together, form the ex- 
treme free edge of the section ; that is, the unattached surface of the artic- 
ular cartilage consists of three or four layers of flattened cells lying quite 
close together and overlapping each other's edges. ' This arrangement has 
caused many observers to believe in the existence of an epithelium. If the 
superficies of fresh cartilage be shaved off thin with a very sharp knife, the 
section will indeed have the appearance of a layer of epithelial cells ; but if 
a thin slice through its substance be examined, the gradual horizontal ar- 
rangement and flattening of the cells will leave no doubt as to the 'true 
structure of its superficies ' (Fig. 4). 

Some observers, Mr. Toynbee among them, found, that in the foetus 
vessels run across the cartilage, even into the middle of joints. In neither 
a fetal hare nor calf, that I had the opportunity of examining, could I dis- 



1 It is not yet quite settled among minute anatomists, whether in fetal develop- 
ment the cartilages ever are covered by a layer of synovial membrane. The subject 
will be again referred to when the latter structure itself is described. I have thought 
it better to leave here the text as it stood in my first edition. 



PATHOLOGICAL ANATOMT. 



cover any such arrangement, nor any trace of it, in a still-born child. 1 Nor 
have I been able to discover epithelium overlying the cartilaginous surface : 
■what Mr. Bowman took for that structure was, I believe, the superficial 
layer of cells as above described, which, in the yet unused joint, is finer 
than when it has been subject to wear and tear. The elucidation is given 
farther on. 

But in early fetal life there is neither bone nor joint, the whole set of 
structures above enumerated are developed iipm a cartilaginous basis en- 
closed in a perichondrium ; the mode of this development bears so direct- 
ly on the relationship of certain parts to the joint and to each other, that 
some description of the process must be given. 

The limb buds of the human foatus appear at the end of- the third 
week — about the sixth or seventh they are marked externally by shallow 
grooves for the divisions of the 
digits and for the different seg- 
ments. The substance of these 
buds, now become lappets, is 
formed from the outer layer of 
the mesoblast (somatopleura), but 
they are covered or enveloped by 
folds of the epiblast. Soon after, 
but I cannot say how long after 
the buds appear, a differentiation 
of the structure takes place, where- 
by a skeleton, consisting of very 
soft, jelly-like cartilage, extremely 
rich in cells, is formed ; not all 
at once — the proximal parts form 
first, the distal afterward, and the 
upper limb takes precedence of 
the lower. This cartilage is simul- 
taneously with, or soon after its 
formation, covered in with that 
perichondrium which afterward 
becomes periosteum. The carti- 
laginous skeleton is without joints: 
this must not be taken to mean 
that a whole limb from trunk to 
phalanges ever possesses -an en- 
tire but unjointed skeleton, for 
cavities, representing future articulations, are formed in the proximal 
parts, while in the distal ones the cartilaginous skeleton is being built. 
Although the primordial cartilage is non-articulated, yet at the points 
where joints are to appear, one may see whitish lines running nearly but 
not quite through the substance. These, though very visible to a low, are 
less perceptible to a high power, with transmitted light ; for these lines, 




Fig. 4. — Cartilage from human astragalus, magnified 
about 700 diameters, showing the perpendicular arrange- 
ment of corpuscles at the lower part, gradually curving 
into an oblique, subsequently into a horizontal, position, 
and drying into scales. 



1 Kolliker could not make out such vessels as Toynbee described. A little further 
on the development of synovial membrane is described. It seems to me that in some 
misinterpretation of these appearances lies the clue to what Mr. Toynbee means by 
'• removing the synovial membrane from nearly the entire surface of the articular car- 
tilage of the condyle of the femur, to which it was attached by a considerable layer of 
cellular tissue " (Philosoph. Trans., 1841, p. 167), and how the cells on the surface 
have been taken to be epithelium-cells, and also certain views concerning vessels on 
the surface of the cartilage. 



10 



DISEASES OF THE JOINTS. 



like the rest of the cartilage, are made up of closely packed and identical 
cells. The structure impresses me as depending upon a different arrange- 
ment of the cell-elements, which (they are so densely packed that no abso- 
lute rows can he seen) seem aligned transversely to, not, as elsewhere, 
with, the axis of the bone. These lines foreshadow the place, and I believe 
also, to a certain extent, the form, of the coming joint. Some time between 
the fifth and sixth week, first near the trunk and in the upper sooner than 
in the lower limb, the cells of this white line begin to undergo changes 
which Luschka calls Verfliissigung (liquefaction). They become, he says, 
clearer and larger, then disappear and leave a cavity occupied by their 
debris and elaborated fluid. 

At this point my investigations diverge from those of other observers. 
I have only seen this condition of enlarged clear cells once, and that doubt- 
fully in a hare-foetus of probably five to seven days old, nor do I wish to 
comment upon Luschka's account of the mode in which the first, the cen- 
tral, part of the cavity is formed ; but this I believe can only apply to quite 
an early stage of the cleavage ; afterward, at all events, a different action 
takes place. The space left between the segments of the cartilage is of 
course, in a cylindrical bone, circular or diskoid in form, but microscopic 
sections present it as a chink of an elongated oval shape. As we trace the 
cells from the undisturbed and unaltered cartilage toward the fissure, we 
find them little changed, perhaps rather flattened ; but toward either 
edge of the slit — that is, near the circumference of the disk — they gradually 
elongate more and more, until quite on the edge of the rift they are simply 
fibre and spindle cells ; the hyaline material (what there is of it) splits up ; 
the cartilage has here changed into a very fine fibre-tissue. Now if the 
end of the rift be focussed, one sees that from this extremity the cells and 
fibres diverge upward and downward, so that opposite the centre of the 
chink the fibrillation and the trend of the elongating cells run directly out- 





Fig. 5— Diagrammatic development of the synovial membrane. Sections of the joints of little finger (hu- 
man f cetus), (diagrammatic) : A, early fissuration cells, becoming fusiform, and fibre-cells, arrange themselves 
in curves from the end of the fissure upward and downward ; B. bifurcating fissure beginning to extend 
along upper and lower margin of Bpaces marked by elongating cells ; C, fissure completely bifurcaled. has 
nearly reached perichondrium ; between the forks is a ring of cartilage altered to fibrous tissue thickest in 
middle, therefore triangular in section; the thicker portion becomes a synovial fold: the perichondrium 
has thickened opposite this ring. 

ward to the perichondrium ; above this they sweep in upward, below it in 
downward, curves (Pig. 5, A). Thus while in the centre the segments of 
cartilage are separated by a space, they are united at the circumference by 
a cellulo-fibrous tissue which cannot be said to cover because it is a part, 
though an altered part of the cartilage. When the fibrous metamorphosis 
is complete, the fissuration no longer follows a simple straight course across 



PATHOLOGICAL ANATOMY. 



11 



(Fig. 5, B) the structure, but divides on right and left of section into two 
branches which follow on upper and lower segment the lines of junction 
between the fibrous and the cartilaginous tissue ; yet not exactly this line, 
but one just within the former, so that a very thin film of it is left for a time 
on the face of the cartilage at its peripheral portion. The result is that this 
structure, which formerly was cartilage and is now a true fibro-cellular tis- 
sue, is left as a ring or rather a short tube round the now sundered limb 
segments — this ring must by the process of its formation be thickest in the 
middle, i.e., opposite the fissure of disjunction — also the ends of the tube 
are not so much attached to, as absolutely growing out of — proceeding 
from — the cartilage, not merely from its edge but from the more.outer 
parts of its face. Fine sections from a fetal finger or toe between the 
sixth and seventh month show fibres running from these spots into the tis- 
sue lying outside the rift, and also that the two structures are one and the 
same. At the angle where the rift ends, and progressive absorption is still 
further separating this fibrous material from the persistent cartilage, little 
fine tufts or shreds may be seen to spring and project a little way into the 
cavity. The next phase, that of the still-born infant, shows clearly that the 
tube of fibro-tissue formed out of the circumferential parts of the cartilage 
is synovial membrane — the thicker parts of it (opposite the fissure) become 
synovial folds. The manner in which synovial membrane originates in 
fibrillar changes of the primordial cartilage, and the mode in which a cer- 
tain thickness of the altered material is left for a time on the, unaltered not- 
in-contact face of the cartilage, accounts for a still existing divergence of 
opinion as to whether joint surfaces are at any period of life (fetal or via- 
ble) covered by a layer of epithelioid cells. 

The figures with which it is attempted to illustrate this description are 
mere diagrams compounded of the views obtained as the section is passed 
under the object-glass — no micro- 
scope could at the same time show 
the minutiae of structure and the 
whole form. We will leave them 
and place under a higher power 
an edge of the rift just inside the 
perichondrium. The upper edge 
represents the joint-surface still in- 
fluenced by the fibrous changes 
going on. At left of the general 
mass a still more striated appear- 
ance marks the fibres tending to 
the upper membrane, the synovial, 
which is seen to be really a part 
of the cartilage, modified as above 
described : outside this is the peri- 
chondrium, become fibrous cap- 
sule, and by further development 
ligament. It is probable that at 

certain joints a more complicated plan of rift-formation is followed— for 
instance, at the temporo-maxillary the first central cavity divides very 
rapidly into the peripheral cornua— and the resultant wedge-shaped piece 
(on section) that is left is therefore larger and intrudes further into the 
chink, and undergoes transformation into fibre-tissue, very partially, re- 
maining at a transition stage between such tissue and cartilage. At the 
knee, whose cavity is almost completely divided ' into two by the crucial 




Fig. 6. — Cartilage changing to synovial membrane 
— foetus 7th mcnth. 



12 DISEASES OP THE JOINTS. 

ligaments, it would seem that the primary rift is not single, nor central, 
but begins by two semilunes, with concavities facing each other ; and that 
running from the anterior condyloid and popliteal notch of femur and tibia 
respectively, folds of the perichondrium are prolonged between them. In 
this joint we have therefore two complications ; one to form the crucial 
ligaments, another to produce the menisci. 

It has been said that as a circumferential layer of cartilage, afterward 
transformed into synovial tissue, is separated from the primordial struc-; 
ture, certain foliaceous tufts or shreds are left behind, being first visible in 
the angle of separation. It may here be added, that as absorption models 
and noes down the central parts of the still too-thick ring, many more 
such tufts are thus formed out of the pre-existing material These, in all 
probability, become afterward synovial fringes — they are sufficiently de- 
veloped in quite young life ; indeed I have seen them in the premature 
child, still-born at about the seventh month. It may be that they develop 
more fully when movement of the joint calls for increased secretion, but 
they probably are chiefly formed when the thickest part of the ring, oppo- 
site the central fissure, begins to be absorbed. They are most abundant 
on those plica?, or folds, which, without injury to the structure, admit of 
motion ; where, therefore, the tissue itself and the peri-synovial structure 
are loose and own a rich vascular supply. In their simpler form they con- 
sist of villous-like folds or saccules of the basement-membrane, each con- 
taining an afferent and efferent vessel, but, as far as has yet been traced, no 
lymphatic. In their further developed form the simple villus sprouts into 
secondary saccules, which may be sessile, like the segments of certain cac- 
tus, e.g., the prickly pear ; or more often are attached by an elongated 
stalk or petiole. These secondary saccules are always extravascular, but 
generally contain a watery alkaline fluid, and when secretion is active, are 
full to bursting (indeed doubtless do often burst) with that liquid. Under 
a high power and with well-prepared specimens the structure shows itself 
as a shred of loose areolar tissue, surrounded by cells closely packed in a 
colloid ground-substance. The cells are not a mere simple coating, they 
are massed, not in layers, but in irregular heaps several deep. The second- 
ary saccules seem to me a colony of such cells pressed out from the mass, 
but remaining attached by an inspissated thread of the jelly-like ground- 
substance. Secretion, more especially of mucin, appears to be the function 
and raison d'etre of these singular little excrescences. They are not con- 
fined to the synovial membranes of joints, but are also abundant on ten- 
dinous sheaths and on bursse, whether normal, accidental, or morbid. 1 

The peculiar structure and characters of the membrane whose forma- 
tion we have thus traced is a subject of very considerable importance, nor 
can, within my limits, full justice be done to the various views which dif- 
ferent anatomists hold. Let me first make the way clear by a description 
of the larger characteristics. 

It will have been understood that even in the earliest period of life this 
structure does not extend over the cartilages of incrustation ; it is there- 
fore never a closed bag into which the bone-ends are pushed, but is com- 



1 1 should like, did space allow, to point out here the singular qualities of the mid- 
dle germinal layer — the richness in cells of all its derivatives — its tendency to for-m 
cavities. For instance, the peritoneal, pleural, pericardial, arachnoid — all joint-cavi- 
ties, sheaths, and bursas — the chambers of the heart — the lumina of all vessels and 
lymphatics, the meshes of areolar tissue, are all the offspring of this layer, and out of 
these last nearly all pathologic cavities arise. 



PATHOLOGICAL ANATOMY. 13 

parable to a tube enclosing at either end the articular bone-mass. At the 
point where the tube-walls come in contact with the cartilage, an intimate 
relationship between the two structures exists ; this relationship is not 
mere adhesion, but is continuity of structure. At this spot, termed mar- 
ginal zone, transition forms of cartilage-cells into areolar tissue-corpuscles, 
of hyaline substance into fibre-tissue, may be seen. A mere tube thus 
formed would then be the simplest and crudest idea of this arrangement, 
but in all joints, parts of the articulating surfaces are not constantly in 
contact, and these are, during non-contact, overlaid by folds inward of the 
membrane ; some of these, which we will call synovial folds or plicae (not 
fringes), contain in their hollow, i.e., outside the cavity, a quantity of fat, 
so that the plica and fat together form projections which Havers mistook 
for synovia-secreting glands, whence the name — which may as well be for- 
gotten — of Haversian glands. Folds of the structure likewise exist in 
parts which cannot thus cover the surfaces of cartilage out of contact, as, 
for instance, certain puckerings in the neighborhood of the patella, on 
each side the tendon of the triceps extensor humeri and elsewhere ; they 
are to allow change of position without tension. The interarticular carti- 
lages or internal ligaments of certain joints cause a complication of the 
membrane, in order to line those parts while excluding them from the 
cavity, in the same way as the abdominal viscera are invested by the perito- 
neum. In some parts, as at the menisci of the knee, such folds are termed 
ligaments. At the hip, too, a long fold ensheathing an artery is called the 
round ligament. Certain other reduplications, chiefly at the knee, are sub- 
ject to the same false nomenclature ; the ligamentum mucosum, soft and 
fragile as it is, forms a glaring instance. 

On all these folds more especially, but also on certain other parts of the 
membrane, the peculiar villous-like processes which have been already suf- 
ficiently described exist. Though each single projection may be termed a 
villus, they collectively are termed fringes, sometimes tufts ; they increase 
the secretory power of the organ. 

This structure is certainly a somewhat modified serous membrane. It 
is lined by endothelial cells, which are separated from the underlying very 
fine areolar tissue and vessels by an extremely delicate membrane. 

This statement is made thus concise and isolated, because some doubt 
has been thrown upon the quality of the membrane, as well as upon its 
cell-lining, and a whole literature has in Germany been devoted to the dis- 
cussion of the subject. In 1866, Dr. C. Hiiter, of Greifswalde, published ' 
a paper, " On the Histology of the Joint Surfaces and Capsules," in which he 
denied to synovial membranes any right to be classified with serous or mu- 
cous membranes, denied that they possessed an epithelial lining, and as- 
serted that their vessels lay naked to the cavity. Now, that Dr. Hiiter is a 
most industrious and deservedly distinguished anatomist and histologist, 
no one would wish to deny ; I least of all, since on other matters I have 
had to enter the lists with him. 2 Dr. Hiiter obtained his results by treat- 
ing the inner surface of the membrane with a one per cent, solution of ni- 
trate of silver, whereby he obtained what he calls — "with the exception of 
the vascular channels, a picture, so confused, whose brown lines and white 
interspaces are in so variable and uncertain relationship, that any clear 
comprehension of the view appears impossible." He then interprets the 
appearances to mean that the synovial membrane has no basement-struc- 



1 Virchow's Arohiv. Bd. xxxvi., Heft 1. 

"Langenbeck's Archiv filr klinische Cbirurgie, Bd. xxiii., S. 254. 



14 DISEASES OF THE JOINTS. 

ture, no cell-lining, but an " epithelioid and keratoid arrangement of cells 
on or mixed with an areolar tissue." But no sooner had this theory been 
published, than many excellent observers — Schweigger-Seidel, 1 Tillmanns," 
Albert, 3 and others pointed out that the silver treatment of the synovial 
membrane is unreliable ; that the pictures which Hiiter thus obtains are 
artificial (Kunstprodukte), the result of a chemical union between the al- 
bumen of the still-adhering synovia and the nitrate of silver forming albu- 
minate of silver, which is deposited in multiform foliaceous and other 
shapes upon the membrane, and thus the investigator covered up with his 
chemical precipitate the structure he was trying to see. Landzert 4 also 
rejects these images, and shows that Dr. Hiiter used a silver solution from 
four to eight times too strong. It is, however, only fair to state that cer- 
tain other observers, viz., Bohm, 1 Bey her, and to a less extent Albert, give 
to Dr. Hiiter a partial support. Yet if the minute anatomy of these struc- 
tures be taken in connection with their origin from the middle germinal 
layer (mesoblast), I do not see how the histologist can escape the conclu- 
sion that the synovial membranes are composed of a fine areolar tissue, 
plentifully studded with cellular elements, and on which the yellow elastic 
fibres are especially abundant. Both the yellow and the white elements 
are arranged as a fine network, the intercussating fibrils meeting at acute 
angles, so that the meshes of the web are much elongated. Toward the 
cavity or internal surface much ground-substance cements the network- 
filaments into continuity, forming a membraniform expansion, whose al- 
most structureless character (save for those filaments) is varied by a free 
distribution on it of connective-tissue corpuscles, on and near the surface of 
endothelial cells." There is then no doubt that the inner surface or lining 
of synovial membranes consists of cells lying in continuity ; in some parts, 
those that are highly stretched, as over the crucial ligaments and near the 
cartilage on the extension side of the limb, this ceU-lining is a single or at 
most a double layer ; in looser parts, and about the fringes, several super- 
imposed, layers of cells may be seen. 7 Among these cells are the rootlets 
of not very numerous lymphatics, and the ramifications of vessels all inter- 
woven with the fine areolar network just described. 

The fluid secreted by this structure — " synovia " — is not quite clear ; it 
is thready, contains an "uncertain quantity of cells and nuclei, which, when 
the liquid is placed in a conical glass, slowly subside, so that the lower 
strata, even in quite normal synovia, are somewhat opalescent. If a little 
of the fluid be rubbed between the finger and thumb, a sensation is 
felt of peculiar lubrication, more marked even than when oil is used in a 

1 Berichte der Konig. Sachs. Gesellsch. Math. -phys. , November 5, 1866. 

s Archiv fur mikroskop. Anat., 1874, Bd. x. 

• 3 Strieker's Histology, vol. iii., p. 555. New Sydenham Society. 

4 Centralblatt fur die Medizin. Wissensch. 1867, p. 371. 

6 Beitr&ge der normalen und patholog. Anatomie der Gelenken, Inaug. Diss. 1868. 

6 Epithelium can only be produced by the epiblast ; hence Hiiter, in rejecting an 
epithelial covering for synovial membranes, is verbally correct ; the endothelial cell- 
layers, however, fully line the sac-surface. Such cells are in all derivatives of the 
mesoblast sufficiently rich, but in none so plentiful as in joint-cavities, typical off- 
spring of that cavity-producing and cell-generating layer. 

'• I shall not here go into the subject of " keratoid bodies," and of serous canals on 
the surface (Hiiter) or beneath the surface (Landzert) ; the matter does not appear to 
me to influence the course of disease. The reader who wishes to follow the matter 
further may consult the authorities named above, and elsewhere in this chapter. 
Albert's article, accessible to all, in the Sydenham Society's Translation of Strieker's 
Histology, will give some idea of the difficulties surrounding this subject 



PATHOLOGICAL ANATOMY. 



15 



similar manner, yet synovia contains exceedingly little fatty matter. It 
owes its lubricating quality apparently to mucin, whose source in the ab- 
sence of mucous glands is of physiological interest. The reaction of the 
liquid is alkaline ; now, if we take a piece of epidermis and rub it in a 
mortar with water, not too strongly alkalized by potash, we obtain a fluid 
having the physical qualities of synovia, and containing mucin. Hence 
there is barely room for doubting that the source of synovial mucin is the 
solution of the endothelial cells in the alkaline fluid secreted by the mem- 
brane ; and this view is strengthened by certain observations of Frerichs, 
who found that while the joints are quiet the synovia contains less than 
half the quantity of mucin which is found when they are employed. The 
three analyses are quoted from that author. 1 



SYNOVIA. 








New-born 
calf. 


Stall-fed 
ox. 


Meadow- fed 
ox. 




965.68 
34.32 


969.90 
30.10 


948.54 




51.46 






Mucin and epithelium 


3.26 

0.56 

1.090 

1.960 


2.40 

0.62 

15.76 

11.32 


5.60 




0.76 


Albumen and extractive 


35.12 


Salts ' 


9.98 







The development of vessels in and about the joints is commensurate with 
the rapidity of the changes above described. Until after the fourth month of 
fetal life no artery penetrates the joint-ends. At about this period the 
larger and more proximal epiphyses begin to be channelled with blood- 
vessels, penetrating inward from the circumference ; but all these stop 
and form loops some distance from the rift, which becomes afterward joint- 
cavity, so that at a very early period a distinction is made between that 
part which is destined to become bone, and that which is to remain non- 
vascular cartilage. The source whence these epiphysal vessels are derived is 
a very rich plexus around the epiphyses ; and as the periphery of the car- 
tilage undergoes that fibrillation which changes it into synovial tissue, ves- 
sels penetrate largely among the fibres, and thus come to lie at that margin 
which I have described and depicted (Fig. 6) as changing into a membrane. 
This network of vessels was named by W. Hunter the circulus articuli vas- 
culosus, and was more especially described by Toynbee as lying between 
the synovial membrane and the cartilage. But this fibrillated layer, de- 
scribed as lying on the cartilaginous surface, is a mere transition phase of 
joint formation ; it is soon absorbed therefore. The vascular margin on 
that surface is also transitional, disappearing at a certain period, varying 
at different joints, but always very shortly after or before birth. The vascu- 
lar zone and the fibrous surface of the cartilage are temporary steps in the 
production of synovial membrane. To carry on the nutrition and absorption 



1 Wagner's Handworterbuch der Physiologic, Bd. iii., Abth. 1, S. 466-7. 

2 The salts are : chloride of sodium, basic phosphates and sulphates, carbonate of 
lime, and earthy phosphates. 



16 DISEASES OF THE JOINTS. 

involved in the transformation, vessels just here are necessary ; when those 
changes are complete, the necessity ceases and the vessels vanish. 

It has been a theory in physiology that, as the synovial membrane is a 
closed sac, it prevents any admission, of air, and that therefore the joint- 
cavity is a vacuum whereby the contact of the articular surfaces is materi- 
ally assisted, Indeed, chiefly produced. Now here some confusion of terms 
surely exists. A vacuum is a space void of air, or of any substance, fluid 
or solid. Contact of two surfaces means that between them there is no 
space. If two smooth and well-fitting surfaces, be they of polished metal 
or of plate-glass, be pressed together so that there is no space between 
them, those surfaces are said to be in contact, and they adhere by means 
of a force called in physics cohesion of contact. Since this cohesion de- 
pends upon the pressure of air on the outer surface of these bodies, it is 
evident if we withdraw air, as in an air-pump, so as to surround them by 
a vacuum, the cohesion must cease. The vacuum theory of the synovial 
cavity is therefore an error. It would annihilate that adherence of certain 
joints' surfaces, such as the hip, which it was intended to explain ; more- 
over, the experiments whereupon that hypothesis is founded are incompati- 
ble and contradictory. These experiments and reasoning whereon this 
vacuum theory is founded were made by E. Weber, of Bonn, and commu- 
nicated in Mailer's Archiv, 1836, p. 54. 

" Now, I will give an investigation into the power whereby the head of 
the thigh is held in juxtaposition with the pelvis. It has been supposed 
that the limb was fastened to the trunk by the strength of the muscles or 
ligaments, because such power is the most visible. More careful examina- 
tion, however, has shown that this is not effected by the power of muscles 
and ligaments, but by a far less perceptible force, namely, by the pressure 
of the surrounding air. 

"The head of the thigh-bone, which fits air-tight into the globular hol- 
low of the acetabulum, adheres in that cavity as the air-tight piston of a 
syringe remains in the tube when its upper opening is closed. 

" As the quicksilver in a barometer is driven upward by atmospheric 
pressure, so is the head of the femur, when there is no air above it, driven 
upward into the acetabulum. I will give shortly the experiments which 
led to this result. 

" First Experiment. — The body was brought into such a position that 
the limb hung freely down. If then the limb hung by the muscles and 
ligaments, it would fall out when those parts were cut through. I severed 
the muscles and ligaments, and the limb did not fall ; on the contrary, the 
joint-surfaces remained in close contact. 1 

" Second Experiment. — Admitting that atmospheric pressure holds up 
the limb, it would fall as soon as air was admitted into the joint-cavity. I 
bored a hole through the wall of the acetabulum through which air en- 
tered — the limb fell, even though the muscles and ligaments had not been 
divided. 

" Third Experiment.— Admitting that atmospheric pressure is alone 
sufficient to support the limb, it should be again supported after having 
fallen out of the cavity when air was prevented from enteiing the joint. 
I replaced the head of the thigh, which had been entirely separated from 
the body, and then, in order to keep air out of the cavity, I closed the hole 



1 This is as easily accounted for by the cohesion of contaot between the cartilagi 
nous surfaces. — R. B. 



PATHOLOG'CAL ANATOMY. ' 17 

which had been bored with my finger— the limb was then supported and 
again fell down as soon as the finger was removed." 

Let us examine these experiments a little closely before I relate some 
of my own. Either the head of the thigh-bone and the acetabulum are in 
actual contact or they are not. If they be in actual contact, cohesion of con- 
tact takes place as between any two smooth surfaces, and a hole bored in 
any part of those surfaces would only affect that cohesion at the place actu- 
ally bored. If, on tbe other hand, they be not in contact, there will either 
be a vacuum (as far as air is concerned) between them, or there will not. If 
air be between them, the theory of atmospheric pressure vanishes ; if there 
be no air between them, but a vacuum, Professor Weber did not re-establish 
that vacuum by merely replacing the head of a thigh-bone in the cavity. 
Neither on the supposition, therefore, of a vacuum in the joint-cavity, nor 
on that of intercohesion of surfaces, can all the results of these experiments 
be explained. I can neither account for the attainment of all these phe- 
nomena, nor procure such results ; they are incompatible with one another. 
One source of fallacy may have been that, in boring the hole, Professor 
Weber unwittingly pushed out the head of the bone with the point of the 
instrument. 

I will now relate some experiments of my own. The first was performed 
for another purpose, and is more fully related in Chapter XV., in which it 
appears as Experiment TTT, 

Experiment I. — The subject was placed upon the table on the back ; 
means of actual measurement by needles, fixed one in the thigh the other in 
the pelvis, were adopted. A weight of 28 lbs. was hung upon a system of 
three pairs of pulleys fastened to the ankle, thus constituting an extending 
force of 756 lbs.: no change in the position of the limb or in the measure- 
ments was found. A hole was made in the inner wall of the acetabulum : 
still no change in the position of the limb or measurements. For the other 
purpose above mentioned a wedge of an inch thickness was driven in be- 
tween the femur and the acetabulum : when this was removed, the head of 
the femur kept the same place, namely, separated from the acetabulum. 
The weight was unfastened, and the head of the femur returned to its nor- 
mal position with a sound precisely like that produced by disarticulation. 1 

Experiment II, July 6, I860.— The subject was placed on the back, 
the weights and pulleys prepared as before, and the same system of meas- 
urement adopted. The capsule of the hip was carefully laid bare without 
puncturing, the tendons of the psoas, and iliacus divided, and weights equal 
to 35 lbs. were hung on the pulleys — a hole was rapidly bored in the floor 
of the acetabulum — a minute and a half after this was done, a suction sound 
was heard, and the head of the femur came out of the cavity. The weights 
were lifted, and the femur replaced and tightly pressed in the cavity, the 
finger firmly held over the hole, but whenever any weight was allowed to 
hang on the thigh the head of the bone fell out, nor could I by any means 
find the slightest difference whether the finger were held over the hole or 
not. There occurred, immediately weight came on the thigh, an oozing 
sound, the sound of squeezing soft moist materials, and the head of the bone 
fell from the cavity. In this experiment the force exerted was very large. 

Experiment III. — The same division of muscles and other dispositions 
were taken. The force was a stone weight on the three-pair system of pul- 

1 These results are incompatible with those of E. Weber's second experiment, in 
which the hip (muscles and ligaments being entire) dislocated on boring a hole in the 
acetabulum. 

2 



18 DISEASES OP THE JOINTS. 

leys. A hole was bored in the inner floor of the acetabulum and enlarged 
so that the head of the bone could be felt with the finger. During the 
work the caput femoris was struck once or twice with the gouge, and the 
femur would start outward or rotate slightly, but the length was precisely 
the same, and no separation of the articular surfaces could be found. (In this 
instance the weight was not sufficient to overcome the cohesion of contact. ) I 
now took off the weight and the cords, and endeavored to dislocate the head 
•of the bone by forcibly twisting the limb in every direction. I most nearly 
succeeded when the thigh was rotated outward and abducted even beyond 
the middle fine. Still it could not be done until the cotyloid ligament was 
divided, and then only partially without division of the Y-shaped ligament. 

Experiment IV.- — All the muscles round the capsule were divided ; but 
the psoas was left entire. The capsule close to the edge of the cotyloid lig- 
ament was cut through, leaving that structure entire. This division should 
have destroyed the machinery for any intrasynovial vacuum, and the head 
of the bone therefore should have fallen out of the cavity, but I had the 
greatest difficulty to dislocate the hip, and could only partially succeed with- 
out dividing the capsule and the cotyloid ligament. 

A curious case occurred to me, which is related at length in an ensuing 
chapter. A man had an opening into the synovial membrane of the elbow- 
joint, which, when he alternately bent and straightened the arm, sucked air 
in and out of the cavity like a pair of bellows. This was a strong man, a 
sailor, who. had a great deal of climbing and other hard work to do, and yet 
had no discoverable tendency to dislocation. Moreover, in amputation at the 
hip or in incising the knee-joint for the extraction of false bodies, we do not 
find any tendency to dislocation, when the synovial membrane is opened. 

The whole vacuum theory is untenable ; the only fact which at all re- 
sembles it is, that cohesion of contact takes place between the joint-surfaces, 
but this is not a vacuum : a vacuum is a space containing neither air nor 
other material — the cohesion we speak of takes place when there is no space 
between the parts interested. 

The fact is, that every joint has some special means, which hold the 
bones forming it in close contact, and such aids as atmospheric pressure 
may yield are but slight in comparison with these. Certainly no man gifted 
with a tolerable appreciation of cause and effect could regard the enormous 
power of the muscles passing from the scapula to the tuberosities close to 
the head of the humerus without considering that their tonicity alone would 
be of large effect in keeping the head of the bone close against the glenoid 
cavity. Any one attempting to resect the head of the humerus in the dead 
subject cannot fail to remark their effects, even as lifeless flesh ; and more- 
over he will find the ligaments and the tendon of the biceps and other parts 
of the greatest importance. Again, if the rotators of the hips and their di- 
rection and attachment be considered, their importance will not be slightly 
regarded, and besides these the psoas, iliacus, and glutei, in fact every mus- 
cle attached to femur and .pelvis, have the same effect. Add to this the 
resistance of the cotyloid ligament, which forms a smaller circle than lies 
within the cavity, and therefore clips in the bone like a circular clamp, and 
we have quite enough to account for the difficulty in dislocating the joint.' 
Besides, there is the capsular ligament, which in certain positions takes con- 
siderable part in holding the head of the bone in the acetabulum. 1 The 

1 In my Experiment II. the weight hung on the pulleys produced a force sufficient 
, to overcome this ligament and open it out ; subsequently, therefore, whether or not air 
was admitted into the cavity, the head of the bone fell out on the application of the 
force. 



PATHOLOGICAL ANATOMY. 19 

knee, elbow, all the joints in the body, have arrangements either of muscu- 
lar force or ligamentous resistance for keeping the articular surfaces in con- 
tact. By this means only, viz., actual contact of the bones, can any assist- 
ance from atmospheric pressure be obtained. A vacuum, i.e., a space 
unfilled by air between the bones, could not be maintained, the synovial 
fluid would bubble up as water does in the receiver of an air-pump and 
destroy the vacuum by filling the space with gas ; or the surrounding parts 
must be forced into such space ; or again the bones would be squeezed to- 
gether, for there is nothing to keep them asunder, and contact, not vacuum, 
would ensue. 

By whatever vessel an articulation be supplied with blood, the fluid all 
comes from the same source, hence the name of the vessel which brings the 
blood is unimportant. The reader will remember that all joints are sur- 
rounded by circumflex, diverging, or anastomotic arteries, which make the 
immediate neighborhood very rich in vessels. This arrangement, although 
no doubt its principal object is to ensure permanence of supply to the distal 
limb segments, has the effect of affording to increased or to pathologic ac- 
tions a prompt and large supply of pabulum ; while the arterial circulation 
in the joint itself can hardly be interrupted by any possible position. In 
the subsynovial tissue the previously ramified vessels form a somewhat close 
network whose meshes are diagonal and polygonal. 1 In the. synovial folds 
these meshes are peculiarly lengthy, and the capillaries are long and either 
wavy or curling. ' 

The fringe receives, each tuft of it, a twig often considerable when con- 
trasted with the size of the little organ ; the twig soon splits into a number 
of close anastomosing branches, which afterward unite again to form a vein 
generally a little larger than the afferent artery. Only the primary villus 
contains vessels ; the addenda or secondary sacculi never do so, save as a 
pathologic condition. 

Nervous Supply. — Every educated anatomist knows what nerves supply 
the chief joints of the body, yet it will be well, since reference to the sub- 
ject will often be made, to give here, in tabular form, the nervous supply of 
different articulations. ■ 

Temporo-maxillary joint . . Masseteric and auriculo-temporal of submaxil- 
lary nerve. 

Shoulder-joint Suprascapular, posterior circumflex, and sub- 

' scapular nerves. 
Elbow-joint The ulnar median and musculo-spiral. (The 

radio-ulnar junction by interosseous of last 

named.) 

Superior radio-ulnar. Same as elbow. 

Inferior radio-ulnar Chiefly by posterior interosseous, slightly by 

median. 
Wrist (radio-carpal) In front ulnar and median, behind posterior 

interosseous. 
Intercarpal Ganglion on posterior, interosseous behind. 

The median to outer ; ulnar to inner side in 

front. 

1 I have never been able, in either fetal or adult joints, to see a vessel lying bare on 
the synovial membrane. Hiiter insists on their lying " naked on the surface." It is 
only fair to say that Reyher (loc. oit.) makes a statement which seems to confirm this 
idea. 



20 DISEASES OP THE JOINTS. 

Carpo-metatarsal Same. 

Metat. phalan. of thumb . . Cutaneous digital, or from branches for inter- 

ossei, median and radial. 

Phalangeals Digital branches. 

Sacro-iliac 1. Superior gluteal. 2. From junction of lum- 

bo-sacro, and 1st sacral. 3. External bran- 
ches of 1st and 2d posterior sacral nerves to 
back. 4. Obturator, probable (Hilton). 

Hip From lumbar plexus. Anterior crural, obtu- 
rator (anterior part). Accessory obturator 
when present. — From sacral plexus. Nerve 
to quadratus, several branches from great 
sciatic, and from lower part of the plexus. 

Knee Internal popliteal and external popliteal ; 

these accompany the articular arteries nerve 
to vastus internus, and to vastus externus; 
obturator to back of joint. 

Ankle Internal saphenous. External branch of ante- 
rior tibial. 

Tarsal joints, and tarso- 
metatarsal Anterior tibial, or one of plantar nerves. 

Phalangeal joints Digital branches. 

The distribution of the nerve-twigs upon the synovial membrane is not 
by an even retiform arrangement of meshes spreading upon or under the 
surface ; indeed, the small size of the twigs entering the joint would be in- 
sufficient for such purpose, and shows that the tissues are not very rich in 
sensitive supply. These twigs split up and take long sinuous courses ; then 
subdivide, and, curling round, terminate in minute plexuses, forming little 
spots just beneath the inner membrane. The arrangement presents, there- 
fore, a pattern as of tendrils and little leaflets — not unlike the convention- 
alized jasmine or pea-blossom in some of Morris's wall-papers. Certain 
parts of the synovial tissue seem pretty rich in these plexus-spots, as, for 
instance, at the outer and front part of the shoulders, the back of the fe- 
moral condyles ; others are nearly destitute of nerves. 

A peculiarity of nervous supply pertains at the carpal joint, which, as far 
as is yet known, has no analogue elsewhere, the posterior interosseous nerve 
ends in a gangliform swelling, twigs from which supply the articulations of 
these small bones. A ganglionic joint-supply is found nowhere else ; even 
those filaments which run from the interosseous nerve to the wrist-joint 
branch off from the trunk above the ganglion. 

Although a scant supply of fine nerve-filaments may be seen in liga- 
ments, no nerve has as yet been found in normal articular cartilage. 

Mr. Hilton ("On Pain and Rest") has pointed out that every joint is 
supplied by branches from the nerves of the muscles moving the articula- 
tion, and from those that supply the skin over the joint. And this is no 
doubt true ; witness the supply of the temporo-maxiUary joint by the mas- 
seteric, and auriculo-temporal, of the shoulder by the supra-subscapular and 
circumflex, etc. At the knee is a remarkable plexus, about and above the 
patella, lying chiefly at the inner part of the front aspect of the limb, formed 
by branches from the saphenous, the obturator, and from the nerves to 
both vasti. In a physiological point of view the results of such arrange- 
ment are beautiful and interesting, and the therapeutic influence of great 
importance. 



PATHOLOGICAL ANATOMY. 21 

To inject with colored fluids the lymphatics of the synovial membrane 
is extremely difficult ; and yet there is no doubt that a plentiful system of 
these minute tubes must exist, because very shortly after filling a joint with 
such liquids, the coloring material is found in the intra-muscular lymph- 
canals of the upper limb-segment. It has hitherto proved impossible to 
demonstrate, on or underlying the synovial surface, a fine network of lym- 
phatic capillaries provided with stomata, such as Klein and others have 
shown to exist on the surface of other serous membranes. 1 The most su- 
perficial lymphatics are immediately beneath the endothelium, but some- 
times the smallest blood-capillaries he over the lymph-channels, i.e., be- 
tween them and the endothelium. These finest lymph-tubes sink then 
deeper into the perisynovial tissue, where they are generally exceedingly 
numerous, surround the blood-vessels with a fine network, and may be. fol- 
lowed into the minutest spaces of the connective tissue. The difficulty, or 
rather, up to the present time, the impossibility of obtaining the colored 
network just beneath the surface, as for instance on the centrum tendineum, 
but merely colored maculae, cannot at present be explained ; but that there 
is a free communication between the fine endothelium-lined lymph-canals 
of the synovial surface and those lying a little deeper is evident from the 
fact that the coloring material passes so quickly to the latter ; sometimes 
so rapidly that the surface loses, even while being examined, its coloration, 
while the deeper parts become more markedly stained. Perhaps this fact 
may in part account for the difficulty of demonstrating a surface network, 
and the diffuse spots seem due to the absorptive activity of the endothelial 
lining. The fringes never contain a lymphatic, nor are there any in the 
cartilages. The lymph-channels of the synovial membrane pass along the 
intermuscular spaces, never into the bone of the limb. 

The material which surrounds and supports the intima of the synovial 
membrane is areolar tissue, whose structure need not be here described." 
I would merely point out that the inner portions are formed chiefly of the 
yeUow or elastic fibres with plentiful cement material, and that as portions 
farther and farther from the joint be examined, more and more white mat- 
ter predominates, until the capsule or capsular ligament is reached, when 
a structure, consisting almost entirely of white tissue, is found. Thus no- 
where is a ligament isolated in the sense that a tendon is isolated. We 
can, it is true, with the scalpel define and demonstrate its edge and bound- 
aries, but this is done at the expense of innumerable bonds and interweav- 
ings that have been cut away. The tissue of ligament, be it capsular, lat- 
eral, or otherwise, is at a thousand points continuous with the perisynovial 
tissues, and always in the process of disease shares, though slowly, the same 
fate. 

Let us once more turn to developmental history. The ligaments are 
formed from the periosteum (perichondrium), which consists of a fibrous 
layer ("white tissue) closely bound to the subjacent parts by a softer, more 
flexible, vascular layer (yellow tissue). As the cartilage in the process of 
joint-formation changes on each side of the cleft of separation into a fine 
synovial structure, the adherence between that altered tissue and the deli- 
cate vascular layer of periosteum still continues, while further out that layer 

1 Hiiter ascribes to the synovial membranes almost total absence of lymphatics ; 
the account in the text is chiefly taken from Landzert, who has not as yet completed 
his promised work. 

' Quain's Anatomy, vol. ii., p. 52 ; Quekett's Histological Catalogue, Todd and Bow- 
man's Physiology, and many other works, may be consulted. 



22 DISEASES OP THE JOINTS. 

maintains its continuity with the denser fibrous stratum. Thus we have 
an uninterrupted gradation from the Outer surface of the ligament to the 
fine cell-pervaded intima of the joint-sac itself. But the ligament, when 
first formed, is a tube running from bone to bone, and in certain joints it 
never abrogates this form, as at the hip and shoulder, but the movements 
of the ginglymoid articulations are such, that the separation of certain 
points of the two bones at the back and front aspects is very considerable, 
while at the sides certain other spots of the bones alter their distance from 
each other very slightly. During the earlier phases of life, while the fi- 
brous structures are very soft, those which lie at the place of greatest mo- 
tion are stretched, changed, and lack development ; while those at places 
which movement does not disturb, grow and thicken to very strong bands. 
•I would, in conclusion, point out the intimate relation to each other of 
all parts which in adults we know, in their sum as a joint — bone-cartilage, 
synovial, perisynovial tissues and ligaments — are all of one parentage. The 
cartilage and perichondrium of the foetus begin to change before birth into 
these various structures. But few joints are complete at birth ; the im- 
perfect state of some articulations, even during some years of viable life, is 
an important consideration. 



CHAPTEE H. 

ACUTE SYNOVITIS. 

Few if any inflammations in the human body own so many causes as 
acute synovitis. Overexertion, a strain, a wound, rheumatic or gouty dia- 
thesis ; infection of the blood by syphilis, by exanthematous disease, by 
pus from a wound or from a secreting mucous surface, whether urethra, 
vagina, or probably also uterus, are all occasional causes of that malady. 
The nomenclature may take, therefore, a different adjective, descriptive of 
the predisposing disease. Thus we have acute, traumatic, rheumatic, gouty, 
and other forms of synovitis, etc. Besides this, names are applied to m- 
dicate the sort of effusion caused by the inflammation: thus, there are such 
names as serous, and as membranous, or, as I prefer to call it, dry syno- 
vitis (synovitis sicoa) ; suppurative and purulent synovitis ; and even some 
writers have added sanguinolent synovitis, an unnecessary term that I shall 
not employ. From the present chapter all the more constitutional forms 
of the malady, such as gouty, rheumatic, and pysemic synovitis, will be ex- 
cluded. Moreover, although suppurative synovitis is occasionally a sequela 
of the simple malady, and may be considered as only a different degree of 
the same disease, therefore logically coming under the same heading, yet 
it is so different in its gravity, results,' and treatment, that I deem it more 
practical to place it altogether in a different chapter. 

Simple Synovitis is a term which denotes an inflammation arising from 
no preponderating cachexia. A malady so named may be lit up by injury 
or exposure, but not by gout, syphilis, pyaemia, or other constitutional con- 
dition. It is much more common in men than women, and occurs chiefly 
between the ages of fifteen and thirty-five ; that is to say, the sex and the age 
most exposed to vicissitudes of temperature and to muscular overexertion, 
the age also of least prudence is the most prone to suffer from the effects of 
those peculiarities. It is much more difficult to account for the extreme par- 
tiality which this disease shows for the knee-joint. When the cause is ex- 
posure, a joint so superficial as the knee will evidently be peculiarly open 
to attack. The same articulation is more obnoxious to injury, partly from 
the almost subcutaneous position of its synovial membrane, partly because 
of its situation between two such long levers as the femur and tibia, laden 

. with the whole weight of the body. But other conditions, such as pyaemia, 
rarely leave the knee unaffected, and nearly always select that joint, if but 
one only be attacked. The form of that malady termed gonorrhoeal very 
rarely indeed spares the knees, and frequently attacks them to the exclusion 
of all others. I should suppose that the large extent and the complication 
of its synovial membrane must be accepted as the sufficient cause of this 
marked preference. 

Opportunities of examining pathologically into the early changes con- 
stituting simple synovitis are extremely rare. One, however, occurred to 

me some years ago, and another quite recently. 



24 DISEASES OP THE JOINTS. 

Case I. — A man, aged forty years, was brought to St. Thomas's Hospital, 
having fallen a considerable height through a skylight, and received an in- 
jury to the head. 

He was bleeding from the right ear, had a severe bruise over the fore- 
• head, and was insensible ; he was taken at once to the wards. The next 
day, also, he remained insensible ; but it was found that the left knee was 
hot and fluctuating, not red, having all the local symptoms of acute synovitis, 
hereafter to be more minutely described. The same conditions continued 
for four days ; on the fifth morning he died. 

More than sufficient injury to account for death was found in the head 
by the gentleman who examined it. I made a careful observation of the 
knee. 

The joint contained about an ounce and a half of synovia, which was 
slightly turbid, opalescent, and in which floated shreds of false membrane, 
some semitransparent, others opaque and white ; these latter being more 
evidently fibrous ; one of the shreds was loosely attached by one end to 
the synovial membrane, the rest floating freely in the fluid. The whole 
membrane was intensely injected, the vessels not being on the surface, but 
as though visible through a film ; in some parts the injection was much 
more violent than in others ; the deepest in color were the fringes around 
the patella, the so-called alar ligaments, and the subcrureal cul-de-sac ; in 
many spots of these parts were actual extravasations, which, again, were 
not on the surface, but beneath a fine film. In the less injected parts of 
the membrane long tortuous vessels could be distinctly traced. The sur- 
face of the membraDe itself was finely roughened ; on holding it up and 
looking toward the light over the surface it was seen to be covered with 
papilla-like or velvety elevations ; it looked like the surface of the duodenum 
when the valvulse conniventes are straightened out. The membrane was 
easily torn, and very easily stripped from the underlying tissue, which wa3 
highly injected and infiltrated by a turbid serum. 

On the inner condyle of the femur was a spot as large as a sixpence, 
whence the cartilage had entirely disappeared ; the edges of the ulcer were 
perfectly smooth, sharp, and clean. The' rest of the cartilage was entirely 
healthy. 

Case H. — E. M., aged forty-five years, was admitted into Charing Cross 
Hospital, July 27, 1875, having the right limb greatly swollen from phlebitic 
cellulitis — the chief enlargement culminating at the knee ; he had also severe 
bronchitis, tympanitis, and was partially comatose from collapse. Mr. Wat- 
kins, of King William Street, gave me the following history : Six days before 
death he had, in some liquor-fight, received a kick on the knee. Next day 
the joint was seen by Mr. Watkins to be greatly swollen. The man neg- 
lected to come into hospital or to submit to treatment until nearly mori- 
bund. The important point is that about one hundred and thirty hours 
before death the knee was hurt, and that twelve hours subsequent to injury 
it was seen inflamed and greatly swollen. 

At the post-mortem examination the joint was found to contain an 
ounce and a half (as near as could be measured) of synovia, so deeply tinged 
with blood as to be the color of claret and water, mixed half and half ; it 
was but very slightly turbid, in it floated a number of blood stained gela- 
tinous masses, from the size of small pins'-heads to that of dried peas. The 
membrane itself was intensely injected, so as to have a nearly uniform deep 
claret-colored hue, in which separate vessels could with difficulty be per- 
ceived ; this coloring was a little more intense at the sides of the patella ; 
and on the inner side a line of darker coloring ran from the knee-cap back- 



ACUTE SYNOVITIS. 25 

ward about an inch opposite to the junction of the bones. On the cruckl 
ligaments the redness was decidedly less. I found no appearance of a 
wreath-like vascularity round the edges of the cartilages, probably because 
everywhere hypersemia was so intense, but the folds were all increased in 
bulk ; owing apparently to their lumen being full of fluid, they lapped over 
the non-in-contact part of the cartilage, but did not intrude between the 
bones. The hypersemia was not immediately on the surface, but lay be- 
neath a transparent but somewhat clouded film which, with the finger-tip, 
could be moved over the vessels ; this laxity appeared also to depend on a 
layer of fluid just beneath the basement-membrane. The surface of the 
membrane, though it had lost its usual polish, did not look, in this mode 
of viewing it, rough. I can only describe its appearance by comparing it to 
a mirror that had been breathed upon. A portion near the patella and a 
piece of the mucous ligament were carefully removed and placed in water, 
when a velvety irregular pile appeared, produced by floating up from the 
surface of hypertrophied fringes. Placed in a cell under a lens, a beautiful 
arborescent growth was seen formed by foliaceous twigs and branchings 
like a very fine moss. Other parts similarly examined showed only here 
increased thickness of all growth, there abrasion-like absence of all cover- 
ing, as though the endothelium had fallen away, which indeed was proba- 
bly the case. The surface of the cartilages was considerably blood-stained, 
but this stain was so superficial that its thickness on the edge of a trans- 
verse section could only be seen with a strong lens. 

The cellular tissue and other parts around the joint and on the limb 
generally were inflamed, congested, and infiltrated with serum. No occlu- 
sion of veins was found, but the larger vessels, and some of the smaller 
ones, were filled with thick though still liquid blood. 

These autopsies represent early stages, and both about the same phase 
of the disease, much more severe in the one than in the other ; yet the con- 
dition found does not represent the commencement of synovitis ; a condi- 
tion so little likely to be seen in the human body that several experiments 
have been made on animals to supplement the deficiency by M. Bouley, 
M. Rey, M. Eichet, and others, some of which will be more fully described 
in the sequel. From the above cases, and from these experiments, we are 
able to foUow with great certitude and succinctness the course of the dis- 
ease, confining ourselves at present to simple synovitis not passing into 
suppuration. 

The first step of the inflammatory act is hypersemia of the subsynovial 
tissue, accompanied, or closely followed, by rapid secretion of synovia into 
the cavity of the joint. This hypersemia is most marked wherever the 
tissue is abundant and lax, as, for instance, on the synovial folds, or the Ha- 
versian glands (fat-pads), etc. On the other hand, where it is tightly 
stretched or closely applied to subjacent parts, the redness is less pro- 
nounced. In most cases of acute character repletion of the vessels relieves 
itself by extravasation into the joint-cavity, and also beneath the basement- 
membrane, leaving blots of chemosis chiefly in the laxer portions ; such 
extravasations are rarely if ever absent in cases arising from injury. The 
hypersemia is always followed by enlargement of the villous-like fringes 
of the synovial membrane. At first this increase is merely due' to their be- 
coming soaked in the effused liquids ; but after the inflammation has 
lasted a certain time, they really increase in size ; their already foliaceous 
form becomes more and more arborescent ; they soon after begin to in- 
vade the surface of the cartilage. This vegetation of the fringes is, how- 



26 DISEASES OF THE JOINTS. 

ever, less marked in acute serous synovitis than in certain other maladies, 
and it will be again referred to when we treat of those conditions. Ac- 
companying these changes is great proliferation of the tissue-cells ; the 
product is in great part pushed or washed into the joint-cavity, rendering 
the fluid opalescent or milky. In the severest cases portions of synovial 
basement-membrane, denuded of their cell-covering, are invested with 
fibrinous concreta, formed either on the surface of the membrane itself, or 
deposited from the fluid of the cavity. 

This fluid varies in different cases very much in quantity, also in con- 
sistency and color, according as blood, fibrin, or cells of different sorts and 
amount are mingled with it. This variation is encountered, as I have fre- 
quently observed, no,t only in different cases, but also in the same cases in 
different phases of the malady. "When rapidly accumulated, the fluid is 
thinner than normal synovia, unless inflammation run very high ; and if the 
puncture for evacuation have been made early, the liquid will be found to 
be transparent. A later puncture, or what comes to much the same thing, 
puncture at the same time in a more acute case — will evacuate an opales- 
cent or even a milky fluid, and this opalescence increases (the disease con- 
tinuing) the later the fluid is drawn off, later I mean with regard to the 
phase of the inflammation rather than to the absolute number of days. 
When the admixture of leucocytes is considerable, so that the fluid is 
milky or creamy, I am in the habit of calling it " puro-synovia." 

If this fluid be allowed to stand for an hour or more in a conical glass, 
the particles producing the opalescence gradually sink, leaving a clear 
transparent liquid above, a milky and thicker one below. The fact is of so 
great importance in the pathological history of these maladies, that it is 
desirable in this place to draw especial attention to it. 

In some cases the fluid will be found stained with blood to different 
hues, from a light pink to blood color. In 1862 I punctured, in consecu- 
tive weeks, the knees of two men which were greatly inflamed from injury ; 
the fluid was as red as blood fresh from an artery. The experience which 
I have since derived from the puncture of joints is, that considerable 
hemorrhage generally occurs in synovitis rapidly following injury ; but is 
less marked as well as less usual after slight injuries, and idiopathic forms 
of the malady. 1 It seldom happens that the blood coagulates in the cavity 
of a joint, i.e., when once mingled with synovia, but it probably does so 
occasionally ; more frequent is the adherence of a clot to the spot from 
which it was slowly poured out. 

On the other hand, an effusion, free or nearly free of blood, may be 
rich in fibrin, some of which may coagulate into lumps that may adhere 
by mere stickiness to any fortuitous part of the surface with which they 
come in contact ; probably also, as in the case of blood-fibrin, may re- 
main adherent to the part which secreted it. Sometimes, but more 
rarely, the effusion, small in quantity, is extremely rich in fibrin, which, 
coagulating with more or less rapidity and adhering to all sides of the 
synovial sac, lines it with a, tough material, not unlike the false membrane 
of certain diseases of the mucous surfaces. Such cases in their furthest de- 
velopment constitute synovitis sicca, 2 and in a less extreme form a transi- 
tion between the serous and the dry synovitis. The student of joint dis- 
eases must, however, be warned against assuming that the gelatinous Little 



1 Cases of tapping are related in the sequel. 
' The Arthro- meningitis cruposa of Volkmann. 



ACUTE SYNOVITIS. 27 

lumps which are so constantly found in the fluid of synovitis are fibrin. On 
the contrary, those that are quite transparent, or at the most opalescent, 
consist merely of a conglomeration of cells produced by migration or pro- 
liferation from the synovial surface. These cells at first float singly, but 
soon, by a universal law of attraction, run together. Most of these glom- 
eruli undergo fatty degeneration, and disappear ; others fall upon and ad- 
here to the synovial membrane, where they may either dissolve or undergo 
some form of development. 

The varieties just described in the constitution of the fluid are very im- 
portant. Let me recapitulate. It may be normal in all but amount, or it 
may be abnormally thin ; sanguinolent and transparent, or both blood- 
stained and opalescent ; it is in some cases (not blood-stained) slightly 
opalescent and mixed with fibrinous floating concreta, or the amount of 
fibrin may be greater^ when the concreta are larger, and some of it solidi- 
fies on a rod shaken freely in the liquid Lastly, the fluid may be milky, 
even creamy, from the admixture of leucocytes, indeed so turbid and white 
as to resemble, more nearly than synovia, the sort of pus which is secreted 
by a mucous membrane in a state of catarrhal irritation. 

These changes within the joint are accompanied by hyperemia, inflam- 
mation and thickening of, with effusion into the surrounding tissues. 
Such aetion occupies in different cases a variable thickness of the peri- 
articular tissues, as measured from the basement-membrane outward. 
Moreover, these tissues will, in certain cases, be chiefly infiltrated with the 
serous, in others with the cellular and fibrinous constituents of the blood ; 
so that not only inside but also outside the joint-bag the inflammation will 
tend more toward the dry or fibrous form in some cases, while in others 
it is more distinctly and markedly serous, and between these two extremes 
every imaginable phase and shade of difference exist. 

The microscopic appearances which tally with the above changes are as 
follows : The synovial cavity, its surface, the tissue itself, and a certain 
thickness of the peri-articular structures, are soaked with fluid effusion, 
which also somewhat infiltrates the villi and fringes. The same structures 
are also filled with a new cell-growth, 1 the parts of which that lie outside 
the joint in the fibrous capsule and ligaments at first soften, and loosen 
those strictures by separating and partially absorbing their fibres, thus ul- 
timately leading either to their induration and thickening, or to their de- 
struction, according to the ulterior changes of the cells themselves. The 
cell-progeny which springs from the deeper, the inner surface of the base- 
ment-membrane, is in part washed into the fluid contents of the sac ; in 
part thickens and increases the villous fringes ; in part and in certain cases 
forms a patch or patches of false membrane on those spots of the synovial 

1 The first edition of this work was published when the doctrine of parenchyma- 
tous inflammation, the Cellular Pathology of Virchow, first made its appearance in 
G rmany, and I felt myself obliged to enter fully into this subject in order to expound 
more clearly my views — since everywhere adopted — concerning the large part that 
granulation plays in joint disease. Since that time the doctrine of the proliferation 
of tissue-cells has been cast into the .shade by the discovery of migratory leucocytes — 
a very important factor in the process of inflammation — but not, as has been too readi- 
ly assumed, the whole process. Tissue vegetation has been too much ignored. I am 
quite certain that much of the inflammatory cell-progeny is the result of that action 
even in acute inflammation, and I have strong grounds for believing that in chronic 
inflammation very little migration of leucocytes takes place. I wish it then to be under- 
stood that when using the terms "cell-progeny " or "cell-proliferation," the parentage 
of the cell-growth is not either way affirmed, except in those instances where it is es- 
pecially traced. 



28 DISEASES OE THE JOINTS. 

surface, which, being abraded of the normal endothelial cells, would other- 
wise be bare. Between these two new cell-growths, inside and outside the 
intima synomdis, that structure itself becomes obscured and often lost. If 
the process go far enough, the joint-cavity is now surrounded, not by the 
complicated structures described in the last chapter, but simply by more 
or less altered and inflammatory tissue, haying a nodular, uneven inner 
surface, and containing fluids of a sanguinolent, opalescent, turbid, puru- 
lent, or fibrinous character. 

At some part of this stage of effusion and thickening most cases of sim- 
ple synovitis stop, either checked by treatment or by the natural limits of 
the disease. The cartilages have not been affected, for they reply more 
slowly to an irritation than do textures which are supplied with blood- 
vessels and nerves ; the ligaments in far advanced instances are somewhat 
altered, being thickened, and the fibres separated. " The above-described 
processes diminish first in intensity, then cease ; retrogression then com- 
mences, the engorgement disappears, and the superabundant fluid in the 
joint decreases in quantity. The cell-broods shrivel, fall into fatty degen- 
eration, are in part absorbed and partly converted into imperfect areolar tis- 
sue, which remains like an eld scar, causing seme thickening, with loss of 
pliability and of elasticity in the peri-articular tissues. If the amount of 
fluid poured forth during the disease have been large, it will have caused 
such distention of the synovial membrane that the latter will perhaps never, 
and certainly only after a lapse of time, regain its normal dimensions, and 
in its cavity the synovia will remain rather more abundant than natural. 
From these causes the joint does not recover its original size ; if it be su- 
perficial, the increase will be plainly perceptible : moreover it will feel stiff 
and weak for years after the disease, being extremely liable to renewed at- 
tacks of inflammation. It may also be left subject to painful sensations 
which Reem to depend on, or at least to be greatly influenced by every 
change of weather, and which, unless the patient be advanced in fife or have 
some constitutional taint, gradually disappear. Any diathesis, be it stru- 
mous, rheumatic, gouty or otherwise, will, in all probability, cause an attack 
of acute synovitis to prolong itself into subacute or chronic malady, marked 
by the systemic peculiarity. These will be considered in future chapters. 

If, however, a simple acute synovitis do not thus stop, it may assume, 
or many cases from their very onset begin with, a freer emigration and pro- 
liferation on and near the synovial surface, which impart to the secreted 
liquid a very different character through, the admixture of leucocytes, or 
tissue-cell progeny. There is no difference between these forms of cell and 
the pus-cell, no clearly marked distinction between synovia charged as above, 
and the same fluid mingled with a certain amount of pus, or in its further 
advanced forms consisting simply of pus. The synovial membrane was in 
our first chapter shown to secrete normally a fluid containing mucin derived 
from the shed endothelium cells. An increase of this shedding and a de- 
creased rapidity of dissolution soon render their accumulation in the fluid 
well marked by an opalescence and turbidity which approximates the liquid 
more and more to muco-pus or indeed to pus. We all know how difficult, 
or rather, in many cases, how impossible it is to distinguish a mucous from 
a purulent leucorrhcea ; how the secretion, not having characters distinctive 
one way or the other, is named from both "muco-pus," the result, it is 
true, of an inflammation, but of an inflammation which affects the mere sur- 
face. 

Identical action takes place on the surface of the synovial membrane, 
producing in the joint the accumulation of a fluid which cannot be distin- 



ACUTE SYNOVITIS. 29 

guished from pus, except by the fact that it usually, unless in the most de- 
veloped forms, is more lubricatory and thready. The results of very many 
investigations into the quality and nature of fluids secreted during synovitis 
convince me that opalescence, milkiness, even creamy puriform conditions, 
are frequent characteristics of such liquids, often, unless examined, quite 
unsuspected. Generally, as the inflammation subsides, fresh contribution 
of cells from the surface ceases ; those already in the cavity fall into fatty, 
mucoid, or granular degeneration and disappear ; the fluid resumes its ordi- 
nary clear synovial character ; the disease is cured. 

But, on the other hand, if the inflammation continue, the constant fresh 
cell-formation renders the secretion thicker, more frankly puriform and 
larger in bulk, setting up a tension of itself a source of danger, while the 
accumulation of pus in a cavity (it cannot, as in mucous tubes, flow away) 
evidently may involve grave consequences. This malady, which I would 
call purulent synovitis, differs from suppurative synovitis in the mere sur- 
face nature of the inflammation and pus-production. It is a far less grave 
condition, being a mere exaggeration produced by some irritation of the 
normal secretion by the surface. While a pus-production in the depths, in 
the substance of the tissues, is altogether abnormal, and only possible when 
some destruction has occurred, nevertheless when (and this is not very 
common) a simple changes to a suppurative synovitis, it is by the route just 
indicated ; firstly, the secreted fluid becomes more and more distinctly puri- 
form ; tension arises, and pus-formation passes deeper and deeper among 
the tissues. 

Such are the changes which take place in the joint itself, and in the im- 
mediate neighborhood. A few words remain to be 1 said concerning the 
effect of joint-inflammation on adjacent parts, chiefly on the muscles, viz., 
certain almost definite contractions and wastings. Whenever a synovitis, 
even though not severe, arises, the limb-segment below assumes a certain 
position, which, save in a very few exceptional instances, is invariable for 
each articulation, while wasting commences. The wasting is not attributa- 
ble to mere rest, since an equal amount of immobility in diseases uncon- 
nected with joints does not produce commensurate atrophy. As a very 
general rule, the flexors are contracted, ' the extensors relaxed, the flexors 
waste but slowly and only after a time ; the extensors quickly and at once. 
These conditions are better exemplified on the joints of the lower than of 
the upper extremity ; for instance, at the hip the ilio-psoas rectus and tensor 
vaginae femoris are felt during inflammation to be tense and hard, the glu- 
teus maximus flabby and pendulous ; this condition, together with droop- 
ing of the nates, being one of the commonly known early symptoms, and in 
a very little time the buttock of that side becomes flat and thin. Again, at 
the knee, while the leg bends and the hamstrings are felt to be cordy and 
tight, the quadriceps extensor is flaccid, and wastes so quickly that two or 
three days after the commencement of a synovitis the outline of the lower 
third of the thigh, looked at from the side, instead of being rounded or 
full, is an absolute concavity, a hollow. We have seen that there is a dis- 
tinct and evident connection between the innervation of muscles and of 
joints ; but anatomy here fails to explain why inflammation of the latter 
should affect the former so differently, why it should produce tension of 

' In the commencement of joint-disease the contraction is active. I must refer to 
Chapters V. and XIX. for the distinction between this and a passive state, called by 
me l ' contracture. " 



30 DISEASES OP THE JOINTS. 

one set, and almost annul even the normal tonic contractility of the other. 
At present we must accept the fact without the explanation ; nor must it 
ever be overlooked, for muscular actions, irregular and abnormal, play, as 
we shall see, a great part in joint-disease, and the prevention of their effects 
takes a large portion of the treatment. 

A form of disease termed dry synovitis is of very obscure etiology. It 
never, so far as I know, attacks other joints than the knee, in which I have 
seen three cases of such malady ; but it may be that some of the very pain- 
ful affections of the adult hip are of the same sort ; the fluid effusion in 
these cases, being transitory, while pain lasts a long time, and anchylosis, 
true or fibrous, according to the duration of the malady, would lead to such 
supposition gathered simply from analogy, not from direct anatomical ex- 
amination, for which no opportunity has offered itself. It appears to me 
probable that the dry form of disease commences as a simple synovitis with 
unusually fibrogenous effusion, that fluid parts become rapidly absorbed, 
and coagulation takes place over the inner lining of the joint-sac. We shall 
see that there is reason to believe that a flocculus or blood-clot, if it chance 
to be deposited on the inner surface of the membrane, causes the spot to 
which it adheres to be the seat of severe pain, which in character is like that 
of dry synovitis, but limited to a small point, and therefore bearable. 

Symptoms. — The symptoms of an acute inflammatory disease of a joint 
are those of inflammation, redness, heat, pain, swelling ; modified more or 
less by the part attacked, as also by the mode or class of inflammation. 

Thus, redness of the joint is by no means a necessary accompaniment 
of synovitis. In the simple form of the disease it is usually absent ; in the 
gonorrhoea!, so conspicuously absent that I have -often believed the joint to 
look abnormally pale. In pysemic conditions also there is generally no 
redness, but not unfrequently a localized blush with sharply defined edges 
will be seen somewhere on the swollen part, usually over, and in the di- 
rection of absorbents and of veins. On the other hand, rheumatic and gouty 
synovitis is accompanied by pretty considerable rubefaction. It is there- 
fore evident that this symptom stands in no clear ratio with the intensity 
of the disease. 

Increase of temperature always accompanies acute inflammation of joints. 
It is more marked, or at least more easily demonstrated, the more super- 
ficial be the articulation ; at the knee more readily than at the hip, at the 
elbow than at the shoulder. The mode in which I have obtained my results 
is as foUows : for some half hour, and frequently much longer, before 
taking temperatures, I have carefully placed the two knees, or two other 
joints in the same conditions as regards covering : I have then chosen the 
same spot in each, laid a thermometer first on the sound side, covering it 
with a thick coating of cotton-wool — retained in place by the fingers — the 
same has then been done with the diseased side. 

A joint affected by acute rheumatism has often a very high absolute 
temperature ; but not relatively to that of the other limb, since the whole 
body is hot. On the other hand, a gouty toe will be very much hotter than 
that of the other side, even as much as 3.2°, as in one of my cases. The 
gonorrhceal and pysemic joints show but little or no perceptible increase of 
heat. The rise of temperature in simple synovitis, according to its acuity, 
is from 1.5° to 2.4°. Of suppurative synovitis I can give but one case since 
I began the thermometric observations ; the temperature here was 3.2°. 
It should be noticed that in cases, such as gonorrhoeal, pysemic, rheumatic, 
in which the thermometer will mark only a fractional rise, the sense to the 
hand is frequently that of very considerable heat. The phenomenon is dif- 



ACUTE SYNOVITIS. 31 

ficult to account for ; it probably is caused by some difference in the sur- 
face-texture, perhaps some electric change may be involved. 

Pain, although always present in acute synovitis, varies, like the two 
symptoms already described, with the sort of inflammation quite as much 
or more than with the degree — gouty, suppurative, rheumatic, gonorrhceal, 
simple, is the order of succession in degrees of pain, presupposing, of course, 
similar intensity of disease as nearly as can be estimated. The form of 
malady also governs the sort of pain : the gouty and the rheumatic-pain 
are in themselves peculiar. The bursting and throbbing sensation of com- 
mencing suppuration is well known, and most of us have experienced, at 
least in some small degree, the bruised sort of feeling and the helpless sen- 
sation of limb produced by a simple synovitis. With pain, properly so 
called, tenderness is closely combined ; badly inflamed joints are tender all 
over, if less severely affected they have special points on which moderate 
pressure causes pain, while the rest of the articulation is not thus sensitive. 
These points are more distinctly marked, and are of more importance in 
subacute and chronic disease, therefore only a few, the most striking, need 
be mentioned here. The point of tenderness at the knee is on the front of 
the internal condyle, about a finger's breadth from the inner margin of the 
patella. At the hip are two spots ; one behind the great trochanter, one a 
little outside the ramus of the ischium, about the posterior edge of the 
gracilis origin. At the elbow a point at the back of the joint between the 
head of the radius and the humerus. At the ankle a place in front of the 
outer malleolus, about where the peroneus tertus tendon crosses the joint. 

Occasionally a particular spot of the synovial membrane will be both 
very painful and tender, and these symptoms will be peculiarly obstinate. 
These spots are not constant like those just indicated, but are here in one 
case, there in another ; their localization appears quite accidental. Such 
occurrences are attributed by Volkmann to deposition on the synovial mem- 
brane of a fibrin-clot. This is very probably the correct interpretation, but 
we have no direct anatomical proof of its truth. 

Swelling is produced by two causes, viz., by hyperemia of and effusion 
of fluid into the peri-articular tissues, and by accumulation of liquids with- 
in the joint-cavity. The former of these predominates in some, the latter 
in other forms of malady. Thus in most cases of acute gout, rheumatism, 
and pyaemie synovitis, the peri-articular very much masks the intra-articular 
swelling. Acute sero-synovitis, whether brought on by injury or exposure 
to cold, is remarkable for the preponderance of enlargement from liquid 
effusion into the joint-bag itself ; indeed, so marked is this peculiarity that 
the name of acute hydrops articuli has sometimes been applied to the 
malady. 1 The sort of joint enlargement produced by the two causes is very 
different : the purely peri-articular swelling is simply shapeless, or it may 
deform the outline of the joint to one side or the other ; it does not fluc- 
tuate, but has a tendency to pit. The intra-articular, expanding from with- 
in, presses the synovial membrane outward ; and, while approaching the 
globular shape, is nevertheless confined within the boundaries of that bag; 
takes more or less its shape, and since the sac is crossed and bound down 
at different points by ligaments, muscular attachments, and similar struc- 
tures, it becomes marked in those localities by depressions and constrictions 
which give a peculiar character to the tumefaction. The shape then of a 
joint thus affected is, to a certain extent, the form of that joint reversed ; 

' The term is bad, because although the presence of fluid may be the most promi- 
nent it is not the mcst essential symptom, which is inflammation. 



32 DISEASES OF THE JOINTS. 

normally those various parts above-named make salience tinder the skin, 
while between them are depressions ; now — i.e., when inflamed — the intei*- 
vals are prominent, the locality of ligament, etc., marked by depressions ; 
thus each articulation has, when thus inflamed, its own peculiarities of form. 
Moreover, and this point alone is almost sufficient for diagnosis, the tume- 
faction in the more superficial joints fluctuates very evidently. 

The Shoulder. — The deltoid looks fuller and broader than the norm or 
than the other side. 1 This is best seen by seating the patient on a low seat 
and looking down on the shoulders from above ; or if this, as will sometimes 
happen, be inconvenient, the surgeon may get the same view by standing 
on a chair, placed close to that on which his patient is seated. The humero- 
pectoral groove is at its upper part nearly obliterated, or rendered indistinct. 

The depression at the back below the acromion is lost — the axilla ap- 
pears to the finger shallower than usual. An inflammation of the subdeltoid 
bursa may be mistaken for synovitis of the shoulder, but this disease sim- 
ply enlarges the outer parts, broadens the deltoid, without giving rise- to 
the other signs just mentioned. 

The Elbow. — Normally, there are depressions on both sides of the tri- 
ceps tendon and olecranon process. Synovitis not only fills them up, but 
changes them to elevations. At the lower end of the outer groove the de- 
pression which marks the junction between humerus and radius, best felt, 
with the finger, is also filled up or rendered indistinct. On a front view 
the joint looks unnaturally broad. When effusion is considerable it even' 
somewhat so separates the bones, that the sigmoid notch does not he close 
to the trochlea ; therefore when the arm is at right angles, firm pressure on 
the olecranon will cause it to yield a little,, as though the part were elastic. 
Fluctuation between different parts of the joint may easily be detected, from 
one side of the triceps to the other, from either of these to above the head 
of the radius, etc. 

The Weist. — JEtound the back of this joint there runs, in acute synovitis, 
a bracelet-like swelling, which is more marked laterally on either side of 
the extensors of the fingers, and between the extensor ossis metacarpi, and 
extensors primi and secundi internodii pollicis ; in front also, at either side 
of the flexor tendons, it is perceptible. It cannot be mistaken for enlarge- 
ment of tendinous sheaths, for these behind are very superficial, generally 
bi- or trifurcated and fusiform, the long axis being parallel with that of the 
arm, not, as in synovitis, at right angles with it ; in front, enlargement of 
the large tendinous sheath produces swelling in the palm and wrist — a bis- 
aculeated swelling. 

The Hip. — At this joint tumefaction is to be sought in the groin below 
Poupart's ligament, and also behind the great trochanter. In the former 
place a rounded swelling will be found about the middle, though rather 
below the groove dividing thigh from abdomen ; it is more easily percepti- 
ble on looking along the surface of the extended limb from the knee up- 
ward than straight down upon the part. In the latter point the swelling, 
simply more or less, fills up the post-trochanteric fossa. If the patient, ly- 
ing on the back, have the hams placed on a rather thin pillow so as slightly 
to flex the hip, and if the surgeon then place the thumb of each hand be- 
low the groins, the fingers in the post-trochanteric fossa, he will feel de- 
cided difference of dimension between the sound and diseased side. When 

1 Let not the acquired difference between the stronger right«and weaker left side 
mislead the beginner, nor (a mistake I have known to be committed) a left-handed 
man be thought to have a swollen left arm. 



ACUTE SYNOVITIS. 33 

the fluid is large in quantity, some swelling may also be felt in the angle 
between the thigh and. perineum. With regard to this joint, it should be 
mentioned that the disease in question usually produces apparent length- 
ening of the limb, but sometimes apparent shortening. ' Swelling, as a sign 
of disease at this articulation, is comparatively unimportant. Two burste 
about this joint may lead to erroneous diagnosis. The one situated under 
the gluteus maximus causes, when inflamed, some obliteration of the hol- 
low behind the trochanter, but the swelling is diffused over a larger circum- 
ference than in hip disease, even to the outer surface of the trochanter 
major, while swelling and tenderness at the groin are absent. The other 
bursa lies beneath the psoas and iliacus as it passes over the head of the 
bone — it must, however, be remembered that this bursa often communi- 
cates with the synovial cavity ; if it be a separate sac, and were to be acutely 
inflamed, the presence of swelling and of tenderness at the groin, the ab- 
sence of any such symptoms behind the trochanter, and at the spot above 
mentioned near the adductor origins, will lead to correct diagnosis. 

Knee.— Acute synovitis of the knee is very readily diagnosed. When 
the intra-articular fluid is pretty copious, it not only obliterates the usual 
depressions, but actually transforms them into elevations. Thus the hol- 
lows which naturally lie on each side of the rectus tendon of the patella and 
its ligament may be so protuberant that those tendons and bone lie almost 
in a groove ; the popliteal space is more or less filled up. If the patient ba 
made to stand with the knee not quite straight and muscles relaxed, the 
surgeon may place his finger on the patella, and pressing it with a quick 
motion backward will feel it knock against the femoral condyles, and he 
will see at the same time the parts around bulge forward, so that the hol- 
low in which the bone now lies is considerably increased ; this might be 
described as " seeing " fluctuation. In many cases, especially when the dis- 
ease has lasted some time, the subcrureal cul-de-sac will be particularly 
prominent." 

Two bursas are situated in front of the knee-joint, a large one between 
the patella and skin, a small one between the ligamentum patellae and the 
tibia above the tuberosity ; this latter sometimes communicates with the 
joint. It is scarcely conceivable how inflammation of either of these can be 
mistaken for synovitis of the knee. The former bursa, when inflamed, 
causes a very prominent swelling over the patella, rendering this region 
markedly protuberant, while in synovitis it becomes concealed and less 
prominent. Inflammation of the latter bursa produces but little swelling, 
which much resembles an enlargement of the tibial tuberosity, but, it never 
rises high enough to be mistaken for knee-joint disease ; moreover, the seat 
of swelling and of pain is much more limited. 

Ankle. — The swelling is chiefly anterior, extending like an anklet round 
the limb ; but is most prominent immediately in front of the malleoli, chiefly 
of the external ; some swelling is generally perceptible behind those pro- 
cesses. It should be remembered — and this diagnostic mark is even more 
important in chronic disease — that the long axis of synovitis t runs across 
the limb, while that of effusion into tendinous sheaths with the line of the 
limb. 

Combined with this subject of intra-articular swelling, mention should 
be made of positions which M. Bonnet believed the limbs to assume, in 

1 This subject of apparent lengthening and shortening will he more fully described 
in the chapter on Hip Disease. 

2 See chapter on Chronic Hydarthrosis. 

3 



34 DISEASES OE THE JOINTS. 

order to procure for the synovial membrane the greatest capacity. I have 
not, however, found that acutely inflamed limbs assume these postures with 
such regularity as to induce me to quote M. Bonnet's experiments here. 1 
In more chronic forms of inflammation and of suppuration in joints pecu- 
liarities of posture are more important. 

The constitutional symptoms accompanying acute synovitis of the serous 
variety are generally very trifling. During the first few hours, especially if 
pain be present, some slight pyrexia, some slight rise of temperature, may 
be noted, but this, if the malady remain simple, very soon subsides. Some- 
what more marked disturbances accompany those more severe forms, as 
after grave injury, when, as we have found (p. 26), blood is often poured 
into the joint-cavity ; as also the cases when the cell-action is rapid, con- 
siderable opalescence of the effused fluid is probable. Indeed severe syno- 
vitis should be carefully watched, not only locally but generally. Any 
rise of temperature, excitement of pulse, heat and dryness of skin, should 
cause anxiety ; and if such change have been ushered in by a rigor, the 
dread of approaching danger is changed to the certainty of evil already 
present. 

Symptoms or Dry Synovitis. — Dry or fibrinous synovitis, whose patholo- 
gical significance I described in a few words, is clinically of great interest. 
It is easily distinguished from the simple or serous variety by the fact that 
heat and usually also redness are present, in these symptoms coinciding 
with the serous malady, while the pain of dry synovitis is far more severe, 
and in the fourth symptom, namely, swelling, the difference is marked both 
in amount, form, and persistence. 

The only joint which I have ever seen attacked with Synovitis sicca has 
been the knee, probably once or twice the hip ; nor have I found recorded 
a case which I could ascribe to this disease in any other joint. Its most 
prominent symptom is pain, which, although various in different cases, both 
in amount and character, is always severe to a degree which bears no com- 
parison with the pain of serous synovitis. The surgeon unacquainted with 
this particular form of disease will probably search again and again for pus. 
In the less violent forms the pain is paroxysmal and remittent, occasionally 
even periodic. I shall shortly quotes case in which the pain recurred with 
almost precise regularity every seven hours, so that the seventh day it ex- 
actly resembled the first. In the most severe forms — and these are terrible 
cases to encounter — pains of the most unbearable acuity rage night and 
day for weeks, although nearly always with some period of abatement 
rather than of intermission. 

Pyrexia is always present, but it bears no proportion to the painful 
symptoms ; that is to say, a suppuration producing such suffering would 
be accompanied by a temperature of 102°— 3° or even more ; but dry 
synovitis rarely raises the thermometer above . 100°, and this only while 
the pain lasts. The skin feels hot and dry in the daytime, though severe 
sweating may occur at night ; the sweat under those circumstances smells 
sour. 

The appearance of the joint is very peculiar, and I fear indescribable. 
It is very little swollen, and the slight enlargement seems rather to increase 
and broaden out the natural prominences, while the depressions, especially 
that on each side the ligamentum patellae, are filled up : the skin, of a dull 



1 In the first edition of this work M. Bonnet's forcible injections into joints and theii 
results were given at considerable length ; subsequent experience has caused me to at- 
tach very little value to them. 



ACUTE SYNOVITIS. 35 

red hue and of leathery aspect, looks lightly stretched over these underly- 
ing parts, and is somewhat shiny; when the disease has lasted a little time, 
there is what I may term a superficial or shallow oedema, almost as though 
the skin itself, but nothing deeper, were infiltrated. The joint has a very 
helpless, good-for-nothing look, and this appearance is increased by ex- 
tremely rapid wasting of the thigh-muscles, more rapid even than after 
fracture of the pateUa, much more so than during sero-synovitis. The pain 
is apparently so intense that it is extraordinary how any being can endure 
it for the length of time that it sometimes lasts, but the disease occurs only 
in unbroken constitutions ; the sort of inflammation, unlike the suppura- 
tive, makes no large call on the system, and the pyrexia is not sufficiently 
high to be of itself an injury. Therefore when a painless interval occurs 
the patient sleeps well, and takes food with ease, often indeed largely. He 
thus, as it were, gains strength for the next attack. 

These cases are fortunately rare, nor can I with precision denote their 
etiology. The usual termination is anchylosis ; yet sometimes the patient 
will get well with a knee somewhat stiffened, chiefly by muscular contrac- 
ture, only to a degree which passive motion and rubbing, followed by active 
movements, will remove (see Case VII.); more rarely still suppuration may 
after a long time appear. 

Treatment. — -Acute Synovitis (serous) rarely requires any constitutional 
treatment whatever. At the outset, if the patient be constipated, a brisk 
purge, containing, unless circumstances forbid, some mercury, is desirable. 
I have believed that in many patients advantage has followed the addition 
of some Colchicum wine to the draught following a pill containing mer- 
cury, more especially if the attack be immediately attributable to some 
exposure to cold. Again, if the urine be highly acid, especially if it de- 
posit lithic acid, treatment adapted to that condition will be desirable. 

More than this is, as a rule, unnecessary, therefore to be deprecated ; 
but every now and then a case will occur of such strongly marked inflam- 
matory character, accompanied by such considerable pyrexia, that medicinal 
treatment is demanded. 

Mercury in repeated doses used to be, and is still by some of the pro- 
fession, employed ; although its advantages in acute inflammations, espe- 
cially on those tending to fluid effusion, is more than doubtful, and has 
decided drawbacks in case the disease assume another phase. I prefer 
subduing the fever by rather large doses of citrate of ammonia in an effer- 
vescent form, especially if the urine be very acid, or by small doses of anti- 
mony combined with the above draught ; or, should pain be pretty severe, 
with opium. I have also used digitalis and atropia (see Formulae V. and 
VL) with good effect. 

Mention has been made of opium and of other calmants. I estimate 
their value in accordance with the symptom-pain. I am sure that in many 
acute inflammations, particularly of joints, pain very frequently acts as a 
direct irritant, and ought to be subdued, especially after injury, to which 
cause a large proportion of the severer cases of synovitis are due. 

In the local treatment, the first great essential is rest, in a good position; 
not merely putting the limb on a pillow and enjoining stillness in any pos- 
ture that may at the moment be most comfortable to the patient, but ab- 
solute and enforced immobility in that position which experience has proved 
to be most conducive to cure. We have seen that when a joint is attacked 
by inflammation the limb-segment below becomes more or less fixed in a 
certain grade of flexure, and that if the disease continue, more especially 
if it become more severe, this degree increases, and often attains an exces- 



36 DISEASES OP THE JOINTS. 

sive amount. Such condition, which I shall call malposture, 1 is, although 
immobility be secured, very antagonistic to recovery ; and even if the in- 
flammation be subdued, the limb will be left in an awkward posture, for 
after treatment, the restoration of perfect flexibility will therefore be un- 
necessarily prolonged and painful. The proper position for the shoulder 
is medium ; that is, the arm should hang by, but a little away from, the 
side, the hand lying upon the lower part of the chest. The elbow should 
be bent at a right angle with the hand midway between pronation and 
supination ; that is, with the thumb upward. For the wrist, a perfectly 
straight posture, the hand in a right line with the forearm, thumb upward, 
is very essential. The hip, when acutely inflamed, should be kept extend- 
ed ; in some cases very slight flexure may be permitted, but the greatest 
care should be taken to avoid adduction ; abduction is less deleterious, but 
nevertheless it is better to obviate that posture also. The knee should, be 
slightly, and only slightly, bent. A perfectly straight position is very apt, 
during acute synovitis, to induce that form of irregular muscular contrac- 
tion called " cramp ; " rotation outward of the tibia must be watched for 
and guarded against. The foot must in all inflammations of the ankle- 
joint be kept at a right angle to the leg. Certain authors recommend an 
angle slightly obtuse ; this, for many reasons, is, I am sure, a mistake. 

It rarely, yet sometimes, happens that, in acute simple synovitis any 
malposture is assumed so strongly that it cannot be redressed ; i.e., 
placed in one of the above positions with ease. If, however, there be any 
difficulty in doing this, or if the attempt cause considerable pain, an anaes- 
thetic is to be administered, and the limb put into the proper posture. 2 
Under the influence of narcosis there is no resistance to restoration of pos- 
ture ; the fixity at this period arises, not from passive contracture, but from 
active contraction of muscle, which is eliminated by narcosis ; there is as 
yet no resistance from the tissues of the joint itself, hence no force is re- 
quired to put the limb into a proper position, but the surgeon should not, 
except simply to effect his object, move the joint at all. Before adminis- 
tering ether, the appliances for fixing the limb should be in readiness. For 
the shoulder, are required merely one or , two bandages, and a wedge-shaped 
pad or cushion (Esmarch's acts very well), to keep the arm a little from 
the side. For the elbow, I prefer a rectangular splint ; if it be of wood or 
metal it should be made of two gutters, one for the arm, one for the fore- 
arm, fastened in their places by a bar of steel or brass, running across the 
angle. More convenient, however, and in most cases more efficacious, is a 
splint of poroplastic felt, leather, or pasteboard moulded on the limb and 
sufficiently broad to enclose half its circumference. For the wrist, an arm- 
splint with hand-portion. The hip often requires careful management, and 
the choice of means will depend in great measure upon the size and idio- 
syncrasy of the patient. The reader is referred to the special chapter on 
Hip Disease, for various means of fixing that joint. I will only say here 
that some extension is desirable, the best means of applying it is either ly 

1 This term is not intended to denote that the joint is in a position which it cannot 
normally assume ; indeed, it is rare that an acute joint-duease produces an amount of 
flexure equal to that which is frequent in the usual movements of the body. The 
term has rather reference to the fixity of the posture and to its deviation from that 
which we know to be most sanatory. I must here forestall what belongs to a future 
subject, that in certain joints these malpostures conduce to subluxation. 

2 This procedure is more frequently required in other maladies, and will he referred 
to again ; the hip must be excepted when speaking of the rarity or the easy rectifica- 
tion of malposture (see Chapter XIV.). 



ACUTE SYNOVITIS. 37 

my extension-splint, or by the Desault on the sound, and weight with 
pulley on the diseased limb. For the knee, an Amesbury splint, fixed by 
the underscrew in slight flexion, and with the foot-piece not quite at right 
angles, is the best. It gives ease and comfort to some patients who are 
restless in bed, to swing the splint and limb in a Salter's cradle. For the 
ankle, the same splint may be used, or a moulded splint to either the outer 
or inner side ; it must, however, reach from half-way up the leg to the ball 
of the great or little toe, according to the side chosen. 

Some surgeons, more especially in Germany, reject splints altogether as 
means of giving rest to inflamed joints, and insist upon immovable ban- 
dages, either of plaster, chalk, or gum. These appliances are in some forms 
of disease essentials ; but I have found well-fitting splints quite sufficient for 
the treatment of simple acute synovitis, and they have certain advantages — 
the surgeon can see the joint and watch its progress, it lies open for any 
desirable application. A drawback to the immovable bandage is, that the 
tumefaction, at first present, will, if the case proceed favorably, subside, 
the appliance then get loose over the joint, but still exercise pressure above, 
favoring blood-stasis in and around the synovial membrane. 

Having placed the limb in the proper position upon its appropriate 
splint, we proceed to the consideration of local treatment. A slight syno- 
vitis, which exhibits but little tension, will get well with rest merely, or if 
of a rather higher degree with the aid of certain remedies to be considered 
hereafter ; but if the inflammation be sufficient to cause considerable se- 
cretion into the joint, producing marked fulness of its sac, the synovial 
membrane should be punctured, in a few cases incised (subeutaneously), 
to relieve the tension. In my first edition I spoke of this treatment with 
commendation, although I had not at that time used it ; very shortly after 
publication of the treatise many opportunities for putting my views into 
practice arose, and I have employed the treatment ever since with the 
greatest advantage. 

The aspirator of Dieulafoy, though it occasionally disappoints, is the 
instrument most easily employed. The surgeon selects that portion of the 
joint where the distended synovial membrane is most widely separated from 
subjacent hard parts ; here he passes the tubular needle into the cavity and 
applies the vacuum. It is desirable to wash the steel with carbolic acid, 
and to dip it just before use into carbolized oil ; it is prudent also not to 
choose the smallest-sized tube, lest any flocculi should block it — a most 
disappointing event. If the whole apparatus be not at hand, one may effect 
the same object in a manner perfectly free from danger, either with the 
tubular needle alone, or better with the addition of an india-rubber tube 
two or three feet in length, and of one-eighth inch lumen. Indeed, where 
I have some reason to suspect the presence of fibrin flakes, I often proceed 
in the manner about to be described, because it seems to me that the strong 
vacuum suction draws such flocculi a little way into the needle, but fails to 
suck them through it, whereas without such power they merely impinge 
against the end and fall, or may be shaken off. The little operation with- 
out the vacuum is thus performed : an elastic bandage is placed with some 
tightness on the joint, omitting between two turns the spot to be punctured. 
Into this I have occasionally passed an unguarded needle, and believe that 
the pressure of the band entirely obviates any danger from ingress of air. 
It is well, however, always to be very cautious ; therefore I fix a small tube 
to the collar of the needle, and fill it with a three per cent, solution of car- 
bolic acid ; while an assistant or nurse holds the end of the tube a foot or 
so above the level of the joint, the needle is passed into its cavity, and the 



38 DISEASES OF THE JOINTS. 

tube is at once lowered, till it hang perpendicularly, or nearly so, down- 
ward ; with the exception of the last two or three inches, this should still 
incline upward, avoiding, however, any shaip bend. Fluid immediately 
begins to flow, that in the curl of the tube acts as a trap to the ingress of 
air, and, the capacity of the tube being already known, we can ascertain 
the amount of secretion withdrawn. It averages in the knee four ounces, 
but may, even in a recent case and first attack, amount to six or seven. 
From the shoulder three ounces is a large quantity ; the capacity of an in- 
flamed elbow is rather less. 

If from the presence of many flocculi, or sometimes from viscid quality 
of the fluid, it be found impossible to empty the sac through the aspirator 
needle, it is better, rather than risk admission of air by endeavors to clear 
the tube, to pass a tenotome obliquely through the same skin-puncture, 
and make in the synovial membrane an opening sufficiently wide to allow 
the liquid to drain into the peri-articular tissues. However it may be ef- 
fected, this emptying of the synovial membrane is very important when- 
ever the secretion is sufficient to cause tension. 

This treatment, far from being severe, is the kindliest remedy, and al- 
ways procures instantaneous or almost instantaneous ease. Moreover— and 
this is indeed the most important point- — it nearly always subdues, almost 
at once, the inflammation. It seems to me, that those who have never em- 
ployed this remedy, are not likely to estimate it at its full value ; never- 
theless certain clinical analogies will show its mode of action. Thus, a 
severe sprain or contusion of a joint will not unfrequently produce severe 
synovitis, with great distention of the synovial membrane, pain, etc. A 
dislocation is very rarely indeed followed by any demonstrable synovial 
inflammation. The latter injury is more severe than the former, but it is 
accompanied by laceration of the joint-bag, which, permitting the escape of 
fluid, prevents distention. Again, a fracture into the joint will doubtless 
set up such irritation as produces hypersecretion, but the result drains 
away, and no marked synovitis follows. Here we must except some cases 
of fracture of the patella, which, and their varieties, furnish a crucial proof 
of my position. When, in such cases, the breach of continuity does not 
extend through the fibrous covering of the bone, a smart synovitis usually 
follows ; when it does involve also this fibrous tissue, "the fluid, excessive in 
amount, infiltrates the neighboring areolar tissue, and synovitis, i.e., any- 
thing beyond the mere irritation, which produces excessive secretion, does 
not follow. 

Hence it is evident that the occasional obstinacy of, and the difficulty 
of curing, a synovitis depends in great measure or entirely on tension, and 
that if we relieve this condition by evacuating the fluid, we shall have over- 
come the chief obstacle to recovery. 

Cold. — After evacuation of the joint, pressure should be applied, either 
with an elastic or other bandage, or now, if it be preferred, plaster-of-Paris 
may be employed ; but it must be recollected, that if the case be severe, 
a repetition of puncture may be necessary, or other means may be advisa- 
ble, which can better be employed if the surface be accessible. Among 
the most powerful antiphlogistic remedies, especially if the joint be super- 
ficial, is cold. This application has, like warmth, been very differently 
estimated by different writers, the cause of the divergence being the 
various methods of application : a wet rag, changed whenever it may seem 
good to the attendant, is sometimes warm, sometimes cool, as also is a 
compress wrung out of hot water ; but real cold applied on a fairly super- 
ficial joint has always the effect of reducing hyperemia. The best method 



ACUTE SYNOVITIS. 69 

of application is to place a number of small pieces of ice in one of the 
large-mouthed india-rubber bags kept by all instrument makers, and so to 
suspend it upon the wires of an ordinary bed-cradle, that while in contact 
with the surface of, it yet may not press upon the joint. Of course watch 
must be kept that as soon as the ice is dissolved it may be renewed ; the 
smaller the lumps the sharper the cold, and the more frequent must be the 
renewal. In some patients, chiefly in those of rheumatic tendency, cold 
produces absolute pain, and in such persons the immediate discomfort is 
not the whole, nor indeed the chief, evil, a state of chronic painful inflam- 
mation, not, I believe, of the joint itself, but of the subsynovial peri-articu- 
lar and tendinous tissues, that which people call a rheumatic joint, is often 
left behind. Therefore I do not apply cold to those in whom I can find 
evidence of rheumatism, to those above forty, unless in fine health, nor to 
those who are asthenic and lax of fibre. 

Heat. — To blow hot and cold is a proverbial reproach, yet there are 
many cases in which we may use either remedy, and certainly a goodly 
number when the choice between the two is doubtful. Cold acts by abso- 
lute constringing the vessels ; for the first few seconds it may be presumed 
that (blood being driven from the surface toward the deeper structures) 
the application increases the hypersemia of the synovial membrane ; but 
after the lapse of those moments the effect penetrates deeper and deeper, 
so that at last the vessels of the joint itself are contracted on their contents, 
and not only does the hypersemia cease, but even a local ansemia is pro- 
duced. This, probably, could not be effected in so deep a joint as the 
hip, but in all other large joints such results follow the application very 
rapidly. Heat, probably, acts as a derivative, for, since under its application 
more blood flows to the superficies, less must pass, at least for a time, to 
the deeper structures having the same vascular supply. In anaemic, rheu- 
matic, gouty, and elderly persons, heat is a safer remedy than cold — but it 
should be really heat, not merely warmth. The most agreeable way to ap- 
ply it, and that producing least weight, is by means of flannel bags filled 
with hot salt, which, like the ice-bags, are to be suspended from the cradle. 
There should be two bags, and while one is in use, the required quantity 
pf salt should be heated in an oven or on an iron plate over a gas-stove, or 
in some other convenient way, to fill the second when the first bag has got 
cool, and thus heat should be kept up for several hours. 

Local Abstraction of Blood is valuable in severe synovitis. Notwith- 
standing the almost contemptuous rejection of this treatment by some 
authorities, I must, from experience, maintain its value. Nevertheless its 
use should be restricted to severe cases in their early stage, when inflam- 
mation and swelling are on the increase, when the joint is hot, and when 
pyrexia, even though slight, be undoubted. Its value is more especially 
marked in the synovitis following injury, especially if rapid swelling imme- 
diately follow the accident, and the case be seen early, previous to stasis, 
which begins on the venous side of the circulation. In dealing with the 
more superficial joints, as the knee and elbow, it is better not to apply 
leeches immediately over them, but rather above them, in the course of the 
larger superficial veins — the internal saphenous for the knee, the basilic, or 
that and the cephalic, for the elbow. A caution as to the repetition of 
bloodletting should be given, for there comes a time when it will do harm, 
namely, when there is no general pyrexia and no local heat ; when, indeed, 
the continuance of the swelling appears to depend as much on a want of 
contractility, a topical asthenia of the vessels, as on any active condition. 

Blisters, or other Counter-irritants, are useless, and at times even hurtful 



40 DISEASES OF THE JOINTS. 

in this stage of serous synovitis. Later on in the malady, and, as we shall 
shortly see, in other forms of synovitis, such treatment, properly directed, 
is very valuable. But while there is acuity of inflammation, hyperaemia, 
and heat, all such remedies are to be postponed until these immediate 
symptoms have ceased, and until our efforts are to be directed, not so 
much to prevent secretion as to promote absorption. 

Many pages more might be written concerning sundry remedies, or 
supposed remedies ; but, in truth, acutely inflamed joints, treated in the 
manner and by the means above indicated, get well, or run on, and this is 
a rarity, to suppuration, which belongs to our next chapter. The patient, 
however, may have either inherited or acquired a diathesis, which, when the 
inflammation subsides (acute surgical inflammations are not diathetic), min- 
gles with, and impresses its form and mode of action on the original dis- 
ease. Thus we may have an accidental or traumatic origin of a gouty, 
rheumatic or fungoid synovitis, and these conditions fall in this work under 
their special headings. But in a person gifted with none of these peculiar- 
ities of constitution the simple serous synovitis will nevertheless leave be- 
hind certain sequelae, whose final disappearance may be very much expe- 
dited by well-directed treatment. 

We have seen in our previous section that a peculiar laxity of the syno- 
vial membrane, ligamentous thickening and other troublesome conditions, 
are apt to be left behind by a synovitis, which causes considerable disten- 
tion of the joint-sac, 1 and these difficulties are generally increased by stiff- 
ness of muscles, etc., as already described. All these, but more especially 
the extra-articular inconveniences, are increased if entire quietude be 
enforced beyond the time when, inflammation having disappeared, such 
rigidity of treatment is needed. The symptoms already described will lead 
the surgeon to know when the time has come for changing his strategy. If, 
then, active inflammatory mischief have been subdued, the joint must be 
examined to determine the state in which it has been left. Distention of 
the synovial membrane and surrounding parts, together with passive, i.e., 
non-inflammatory accumulation of fluid evidently dictate certain aims, viz., 
to promote absorption and contraction, while absence of laxity or fluid 
accumulation, but considerable crackling, lead our endeavors in a different 
direction. 

In the former of these conditions any form of counter-irritant or vesica- 
tory is, to a certain extent, useful. An ordinary blister, applied in a superfi- 
cial joint not immediately over the synovial membrane, but a little higher on 
the limb. The liquor vesicatorius, iodide of potassium ointment, or the strong 
tincture of iodine (Formula, Iodine), may, any one of them, be employed ; 
but in using such applications it must be remembered that any considera- 
ble vesication will, for a long time, prevent the use of some of our most use- 
ful remedies — pressure and rubbing. While, therefore, we may judiciously 
employ cantharides or similar counter-irritants, their action should stop just 
short of vesication, and the application be repeated on another part of the 
skin in the immediate neighborhood. 

If under those circumstances pressure be at the same time desired, this 
can be accomplished by covering the irritated surface with a smooth layer 
of cotton-wool and applying an elastic bandage, either the solid india-rubber 
or, which I prefer, elastic webbing, in the use of which care must be taken 
not to strain the material too tight, lest obstruction of circulation be pro- 



1 Evacuation of the fluid by puncture or incision obviates these results, if it be prac- 
tised early enough, almost entirely. 



ACUTE SYNOVITIS. 41 

duced. If the patient be in a fit state to use a little the. diseased limb, it 
may be desirable to add to pressure a little support, as with a strong strap- 
ping-plaster — for instance, the Ung. Resinse spread upon a stout twilled 
calico, cut in strips, and covering the joint smoothly and firmly. Some 
practitioners think highly of certain medicated plasters, as the ammoniacum 
and mercury, the warm and the iodide of lead plaster. While believing 
that the chief use in strapping a joint is mechanical, I cannot deny a proba- 
ble action in some of these plasters, 1 and do not object to them if only they 
r adhere firmly enough. 

The stiffness is best overcome by rubbing, combined first with passive 
and then with active motion. If the joint-attack have been unusually severe 
and protracted, more especially if of traumatic origin, such immobility may 
be left, that restoration by gradual motion will be a very slow and even pain- 
ful process ; in such cases much time and discomfort are saved by straight- 
ening, and otherwise moving the limb during ethernarcosis. A full descrip- 
tion of the method is given under the heading false anchylosis. Nothing 
need here be added, save that repetition of the manoeuvres is very rarely 
required, but that passive motion on the next and following days should be 
kept up. The elbow and the knee are the joints which most usually suffer 
from protracted difficulty in recovering free motion ; for both I am in the 
habit of ordering forms of passive or semi-passive movement, which I find 
very valuable ; that for the knee, as being the more simple, I will describe 
first. A good many years ago it suggested itself to me that I might relieve 
the uncomfortable grating, of which a patient, using passive motion, com- 
plained, by causing him to do this under extension, and I have since used 
that device. Let the patient sit on a table — one without drawers or any 
obstruction under the flat — taking care so to place himself that all the back 
of the thigh is supported, the edge of the table coming close to the ham- 
strings. Let him swinglhe leg backward and forward in measured rhythm, 
having a one, two, or three pound weight attached under the sole of the 
foot by a handkerchief, napkin, or bandage, tied sandal-wise. The larger 
weights are of course "adapted to stronger persons, but are more especially 
indicated if grating be coarse and harsh. One convenient way of fastening 
the weight, giving every facility for variation, is to make a long bag, about as 
big round as the wrist, in the centre of which the desirable quantity of shot 
is placed, and the rest is used to tie round foot and ankle. If we chiefly re- 
quire to obtain mobility in the direction of extension, the patient, instead 
of sitting, may he prone on the sofa, his knee just on the end protected by 
a soft cushion, a slight weight, from one to two pounds, fastened on the 
foot, and let the leg be swung up and down. The same intention can be 
carried out at the elbow if the patient sit sideways on a chair and hang the 
arm, rotated inward, over the back (which must have no cross or centre 
rail). A weight must be attached to the wrist, and of course the upper arm 
must be guarded by a cushion ; if extension be more particularly wanted, 
the back of the humerus, just above the elbow, may be rested on the table, 
and the arm swinging will give the weight all desirable force. Eubbing, 
pressure, and shampooing, sometimes the douche, more often hot bathing 
and wet compresses will, in the absence of diathesis, clear away the stiffness 
of a simple synovitis ; but the means, if obstruction be considerable, must 
be carefully and perseveringly used. 

Shampooing also has great effect, when properly used, in promoting the 

1 1 must strongly warn practitioners against using the last-named drug on persons 
of gouty habit, or even of that hereditary taint. 



42 DISEASES OP THE JOINTS. 

absorption of any hypersecretion still remaining in the joint. Dr. "Witt 
and Dr. Mosengeil have described various methods of " massage," as also 
their physiological effects. 1 Perhaps we need hardly subscribe in full to 
their distinctions, nor entirely credit different forms of rubbing with such 
very distinctive results ; but yet may fully believe that pressure and fric- 
tion, in an upward direction, will stimulate lymphatic and venous absorp- 
tion, even press some fluid into the lymphatic rootlets. 

In synovitis sicca, the treatment must follow somewhat different lines. 
In the first place the severe pain necessitates anodynes, either hypodermi- 
cally or by the mouth. Sudorifics or diuretics, generally with ammonia, 
are useful. Aconite, I have thought, has had decided good effects. After a 
time quinine is of decided benefit. Locally warm moisture is better than 
cold, which, though it may alleviate for a time, brings on recurrence of the 
pain and seems to prolong the disease. Belladonna and glycerine, in equal 
parts, spread on strips of lint and laid smoothly on the joint, certainly after 
a time relieve. The oleate of mercury with atropia is decidedly useful. 
After the most acute phase has passed, blisters in the neighborhood of the 
joint, even going on to vesication, may be employed, and when the surface 
has quite healed, an application composed of iodide of potassium, and iodide 
of lead ointments, either in equal parts or a little varied from this, may be 
applied on lint for four to six days, often with the result of diminishing the 
hard swelling. One of my patients gained ease and advantage by a local 
use of the lamp-bath, which, by means of an india-rubber sheet, can be ar- 
ranged without much difficulty. 

Case HI. — George M , aged 27, laborer, admitted into Charing 

Cross Hospital, under my care, April 21, 1876. Having three days previ- 
ously fallen from a cart and hurt the right knee ; he thought little of the 
matter, but went on with his work. The knee- became more and more 
painful and swollen ; he could not sleep, and came to hospital in a cab. 

The house-surgeon put the knee on a Maclntyre splint, keeping the 
patient in bed. When I saw him in the middle of the day, the joint was 
greatly swollen, the subcrureal bursa felt like a large elastic pad over the 
front of the thigh. The.man complained of great pain ; his pulse was full 
and hard, temperature 100.4°. I passed an aspirator needle into the syno- 
vial sac above and to the inner side of the patella, and drew away four and 
a half ounces of synovia, perhaps a little thinner than the normal The 
joint was then rather tightly bandaged, and the limb replaced on the splint. 
That same night he slept perfectly well without opium. 

April 24th. — The joint was nearly the natural size, and was not painful — 
temperature normal since the operation. I ordered that on the 26th the 
limb should be taken from the splint, the joint moved, and then strapped 
with strong calico, spread with resin plaster, and after three days passive 
movement used. 

April 28th. — The man is anxious to go out, but he is told to remain 
another week. , 

Case D7.— Mr. L. F., aged 34, fell with his horse at a fence, the horse 
upon his left leg ; he got home with difficulty, and when I saw him six 
hours after, March 4, 1879, he was suffering considerable pain both in hip 
and knee, but chiefly in the knee, which was swollen, but not very mark- 
edly. The limb was placed on a Maclntyre splint, and a large ice-bag laid 



i Langenbeok's Arohiv, vol. xviii., p. 275, and vol. xix., p. 439. 



ACUTE SYNOVITIS. 43 

upon it. A sufficient purge, chiefly of podophyllin, was given, and a draught 
of half a grain of acetate of morphia at night if he was restless. 

March 5th. — In spite of the draught he had a good deal of pain. The 
knee this morning was swollen, and very tense— a mark of a bruise on the 
inner side extending up the thigh. I put round the knee and splint an elas- 
tic web bandage, leaving a gap on the outer side, through which I passed a 
tubular needle, provided with india-rubber drain, and drew off forty-three 
drachms of fluid, looking like half-arterialized blood ; but it was treacly, and 
with the peculiar lubricant feel of synovia. Floating on this fluid were sev- 
eral flocculi of much the same color, although when viewed against the white 
background of the bowl they seemed much darker. Soon after the joint- 
sac was thus emptied, the patient felt much easier, the elastic bandage, 
being now too loose, was reapplied. Over this the ice-bag was still used. 

The fluid, left to stand, deposited red blood-corpuscles and leucocytes ; 
also a few fibrinous clots. 

March 6th. — The patient slept a good deal in the morning ; neverthe- 
less he passed a good night, the knee being very little painful, but filling 
again. 

March 10th. — One spot on the inner side of the knee ; three fingers 
breadth above the patella, there is a very painful and tender spot. Whether 
the synovial membrane was here directly bruised, or if some other cause for 
this tenderness exist, it is impossible to ascertain. With the hopes of pre- 
venting the joint filling again, the blistering fluid has been used, but only 
to strongly redden, not to vesicate ; nevertheless fresh secretion took place, 
and there was some little tension. The patient was very anxious to have 
the joint tapped again, which was therefore done. The fluid was now only 
tinged with red, but it seemed thick, i.e., inspissated, and had an opales- 
cent look. This, left to stand, deposited abundance of leucocytes ; some 
glomeruli, formed entirely of those bodies, conjoined apparently in a homo- 
geneous jelly ; also a few fibrinous concreta. 

The puncture wound was covered with collodion, the limb enveloped in 
a flannel band, and then in plaster-of-Paris. 

March 24th. — The patient has been comfortable ; to-day the plaster was 
removed ; the knee had nearly regained its natural size : the tender spot 
above mentioned still gave pain on pressure, but not by any means as much 
as it did. Passive movement and rubbing, then more movement and swing- 
ing the leg, were ordered, and a leather splint made, to be worn at night. 

April 1st. — The joint may be said to be well ; the patient walked a little 
without difficulty, but could not go far. The muscles of the thigh were 
weak ; yet a few days more exercise will cure. 

Case V. — James MacS. was admitted, under my care, into Charing Cross 
Hospital, January 6, 1880; with greatly swollen and very painful knee. He 
had an old gonorrhoea ; he had had no shivering, no polyarticular affection. 
I did not look upon it as a gonorrhceal synovitis, for which he was sent in, 
but as simple synovitis in a man who had gonorrhoea. The swelling, too, 
was entirely intra-articular, the patella knocked plainly, the subcrureal sac 
felt as big and almost as hard as a cricket-ball. The joint was tapped— the 
fluid looked like pus, i.e., was laden with leucocytes. The man required no 
fresh tapping, merely ice and splintage, and was discharged, cured, on the 
1st of February. I do not consider that there was any connection between 
this purulent condition of the joint-fluid and the existence of a gonorrhoea. 
The local condition — viz., an enlargement entirely intra-articular, the gen- 
eral condition, absence of rigors, a temperature not above 100° Fahrenheit, 
and mon-articular joint-affection, forbade this idea. 



44 DISEASES OP THE JOINTS. 

Case VL — In May, 1876, 1 was requested by Mr. Bannister, of Oxford 
Street, to see with him a lad, aged 16, who four days previously had fallen 
just as he was starting for a long walk. On returning, his right hip was 
painful, and he could only get along very slowly ; he arrived home very cold 
and in great pain. Next morning he could not get up, and for the next few 
days his troubles greatly increased. When I saw him, with Mr. Bannister, 
he was lying on the left side, his right thigh was thrown over its fellow, 
and rested on the inner condyle on the bed ; it was very much bent on the 
abdomen and adducted, the slightest attempt to move it caused him to cry- 
out fearfully. Chloroform was given, and under its influence he was 
turned on the back ; the weight of the limb then caused it to fall of itself 
nearly straight ; a very little additional traction with the hands placed it in 
perfectly good position. A weight of three pounds was then suspended on 
the limb, which was further immobilized by an arrangement of an addi- 
tional sheet. Examination of the hip when thus straightened showed there 
to be considerable effusion in the joint, which manifested itself both at the 
lower groin and behind the trochanter. Mr. Bannister undertook to watch 
this, and to let me know if it increased. In two or three days I received a 
message from that gentleman, saying that the tumefaction had nearly dis- 
appeared. In four days more some flying blisters, alternately on the two 
spots above named, dissipated the last remains of tumefaction. 

The pain, which, while the limb was in malposture, had been intense, 
almost disappeared after restoration of a good position. Some morphia 
had been given on the first two evenings, but after that, was discontinued as 
unnecessary. In three weeks the young fellow was walking about with ease. 

Case VII. — Mr. H., in getting into a railway-carriage while in motion, was 
struck on the inner side of the knee, and thrown backward on the platform. 
He felt no pain or uneasiness, save a little stiffness, for fifty hours after the 
accident, when a sudden stab of pain occurred. Four days after the fall, 
viz., on May 15, 1872, he sent for me. I found him in great pain, but dur- 
ing the night, his wife told me, he had been in absolute agony. The pulse 
■was 98 ; the thermometer marked 102.2°. The tongue was clean ; but white, 
and indented at the edge by the teeth. In the middle of the thigh in front, 
and extending to the inner side, was a bruise. The knee was, as verified 
by comparative measurement, very little swollen — it did not fluctuate nor 
pit ; it was rather hard and leathery in feel — the skin seemed somewhat 
immovable over it. The most conspicuous change was that of shape — the 
usual markings of points of bone or tendon being merged in the peculiar 
square look of the limb — a squareness which singularly contrasted with the 
rounded shapelessness of certain synovial maladies, and the definite form 
of sero- synovitis, while its resiliency and want of fluctuation also were re- 
markable. The knee was evidently hotter than the other ; manipulation 
produced but slight discomfort. Pain came on in paroxysms, irregularly, 
and chiefly at night. The joint was a good deal flexed, and the thigh nearly 
an inch less in circumference than the other placed in the same position. 

For nineteen days and nights these paroxysms of intense pain con- 
tinued. I saw him in two of them, and they seemed most severe. He was 
treated by placing (during narcosis) the limb in a good position on an 
Amesbury splint, slung in a Salter's cradle ; hot application of bicarbonate 
of potash, under thin mackintosh ; belladonna and glycerine ; by hypoder- 
mic injection of morphia ; effervescent ammonia ; effervescent ammonia with 
wine of colchicum ; occasionally by drop doses of aconite — also by quinine. 
At the end of three weeks by blisters above the joint ; afterward blue oint- 
ment was applied to the knee. 



ACUTE SYNOVITIS. 45 

On the twentieth day after I first saw him decided remission com- 
menced, and in five days more almost entire freedom from pain set in. A 
fortnight after I found that the joint enjoyed a small range of perfectly 
free and painless movement — at either end of this arc a sharp check was 
experienced. Passive movement effected little improvement, but produced 
no return of inflammation, though persevered in for ten weeks. Under 
ether the knee was flexed with little force, when, with a sharp snap, some 
morbid band was broken, and full movement was at once restored. This 
freedom was less when he became conscious, but sedulous exercises quite 
restored full mobility in about three weeks. 



CHAPTEE m. 

SUPPURATIVE SYNOVITIS. 

The description in the preceding chapters of pathological- changes oc- 
curring during serous synovitis, includes an account of how the previously 
clear synovia may become opalescent and milky from admixture of cells ; 
it was shown not only that the difference between such fluid and pus is one 
merely of degree, but also that even this degree is often overstepped, and 
the fluid in the joint becomes, both chemically and physically, pus, but a pus 
secreted merely by the surface. Such change, when gradual, by no means 
brings with it or is accompanied by marked increase in the urgency of the 
symptoms ; indeed it may and does often arise when the first violence of 
the malady has somewhat abated, the separation of a redundant cell-brood 
from the free surface being, under such circumstances, the climacteric term 
of acute inflammation, the casting away of a morbid production. It may 
happen — indeed it was at one time thought to be a common event — that 
an acute serous synovitis may, whether or no it pass through the phase 
just figured, suddenly put on a graver aspect and run into suppuration of 
the joint. In point of fact, however, this is not the usual course of events ; 
an inflammation of the synovial membrane which is to become suppurative, 
betrays at once its character, and, even before pus can have had time to 
form, shows, by the local and general symptoms, that a more serious malady 
than a mere simple synovitis has been set up. Moreover, a large propor- 
tion of joint-abscesses follow injury, especially penetrating wounds of the 
■articulation, markedly if such wound be made .with a foul instrument, or 
under circumstances which have necessitated long exposure to the air. It 
is a mistake, however, to suppose, as was, I believe, generally supposed 
prior to the first edition of this work, that wounds of joints are of necessity 
followed by suppuration of the cavity. I reported then several cases, and 
have seen many since, in which the accident was followed by no such ill- 
effects ; nevertheless the surgeon must always watch joint- wounds with care, 
even with anxiety. 

When a suppuration of the joint (not merely a purulent secretion from 
its inner surface) has commenced, the histological changes are in all re- 
spects the same, whether it have or have not been preceded by a period of 
less severe inflammation, or whether it have at once followed a wound. So 
rarely, however, do opportunities of examining human articulations in the 
earlier phases of suppurative synovitis occur, that animals have frequently 
been made the subject of experiment, in order to demonstrate the first steps 
of the process. Among these M. Richet's observations may be quoted : 

" Having opened a joint in several dogs, and sometimes several joints of 
the same dog, I was enabled to establish the following facts ; but not with- 
out difficulty, owing to the extreme agitation of the animals, and to the 
small extent of their synovial membranes. 

" The membrane, either exposed or touched with some irritating liquid, 



SUPPURATIVE SYNOVITIS. 47 

could be seen after the lapse of from four to six hours to become reddened, 
the redness appearing to belong more particularly to the subserous tissue. 

" After ten hours the membrane lost its polish, but I never at any time 
could find that it was drier than in the normal condition. This dryness of 
the serous membranes in the first stage of their inflammation is admitted 
by all authors, and yet nothing is further from proof. This peculiar state, 
which has never been shown by direct observation to exist, has been in- 
vented to explain their crackling (bruit parchemine). May this not be ex- 
plained by the loss of polish, itself determined by the falling away of its 
epithelial layer ; or, to speak more clearly, may it not be caused by the loss 
of then - habitual flexible condition ? On the next day the redness appeared 
more superficial, and more particularly as though distributed in patches 
resembling spots of ecchymosis. The serous surface was dull, and covered 
by a sero-sanguinolent layer, which soon became more abundant. After 
forty-eight hours the synovia became thicker, and assumed the color of 
wine-lees ; the synovial membrane beneath this began to get granular. 

" On the third day, real but badly formed pus flowed from the wound ; 
the synovial membrane at this time was nearly uniformly red. There was 
much sanguineous congestion in the neighboring tissues, and when the 
synovial surface had been weU wiped with a piece of linen, there were seen, 
on looking against the light, fine granulations, which I would compare to 
those observed on the inner surface of the eyelids in old blepharitis, but 
they were more marked. During the following days all these appearances 
increased, and from the fifth to the twelfth day was observed upon the sur- 
face of the synovial membrane a pseudo-membranous exudation, which 
seemed to me to form intimate adhesions with the granulations above de- 
scribed. At a latter period the synovial membrane could be seen to swell, 
to form a fringe, a true chemosis, round the cartilages, which, in the midst 
of all this disorder, preserve their normal whiteness. 

" In one case, when I killed the animal sixty-three days after having in- 
jected pure alcohol into his synovial membrane, causing thereby a freely 
suppurating inflammation, with neighboring abscesses, I found these syno- 
vial fringes encroaching so greatly upon the cartilaginous surfaces as almost 
to conceal them ; nevertheless they could be displaced by the end of the 
finger ; and then it was perceived that they not only had contracted no ad- 
hesions to the cartilage, but also that these latter had suffered no change, 
except a slight loss of brilliancy, and that they were thinner than natural." 

It appears to me not only an interesting but an important study to trace 
these actions and to examine their source and character. Acute suppura- 
tion, wherever it may occur, is distinguished from other forms of inflam- 
mation by an enormous production of cells, not only in the pus itself, there- 
fore elaborated from the surface, but also in the tissues. For a considerable 
distance from the pus-producing focus, every cell-space and every cranny ap- 
pear, under the microscope, crowded and crammed with cell-forms. These 
innumerable cells, and the masses of granular protoplasm which in the tis- 
sues surround them, must, according to those who would explain all inflam- 
matory products by means of Cohnheim's migrated cells, originate and 
be the descendants of white blood-corpuscles ; while the earlier cellular 
pathology of Virchow would ascribe to them a different parentage, viz., the 
tissue-ceils which have largely and freely proliferated. Though far from 
denying that in synovitis, and especially in its suppurative form, a number 
of white blood-corpuscles do migrate from the vessels into the tissues, and 
do there gather around themselves a liquor, I confess that I cannot ascribe 
all the cells and all the fluid to this one source, but would deem that the 



48 DISEASES OP THE JOINTS. 

tissue-cells largely proliferate, and in my opinion contribute the greater 
amount of the cell-formation, etc., which is the essence of a pus-producing 
inflammation. The synovial and subsynovial tissues are, unlike the parts 
upon which Cohnheim's observations were made, very rich in cell-elements, 
and hence, although in the cornea, mesentery, and other parts experimented 
on, such elements may take a small or even no share in suppurative actions, 
we cannot therefore deny to more largely gifted parts actions to which they 
seem peculiarly fitted. I would then hold that both the vessel theory 
(Cohnheim) and the tissue theory (Virchow) are true, as far as the synovial 
membrane and its immediate surroundings are concerned, and I cannot 
but think the latter takes the larger share: 1 Certain is it that not merely 
the blood-vessels, nutritive channels, and lymphatic rootlets, but also the 
tissues participate in the process, while the intense pain that precedes the 
formation of pus would seem to show that other nerves besides the vaso- 
motor are involved in the action. The pathological and histological narra- 
tive of a case unchanged by surgical interference runs as follows : 

At first, inflammation, with hypersemia, intense redness, spots of chemosis 
and cell-proliferation in the synovial membrane itself and in the peri-articu- 
lar tissues ; the inner surface loses its polish and becomes slightly rough- 
ened ; in fact the whole condition is that described at p. 56, Case II. The 
synovia effused, usually small in quantity, is frequently blood-stained and 
very generally fibrinous ; the fibrin separates in distinct clots, which after- 
ward appear as flocculi. In a very short time rapid cell-accumulation, 
either from the tissues or from migrated corpuscles, or both, render this 
fluid opalescent, milky, creamy. The subsynovial tissue is also gorged with 
fluid, among which are innumerable granules and cells. The structures in 
the immediate neighborhood of the joint are but slightly infiltrated with 
fluid ; but farther away more and more liquid imbibition is found, and at 
the circumference of the inflammatory action the effusion is simply a serous 
or sero-sanguinolent liquid, containing but a few bodies, similar in all ap- 
pearances to white blood-corpuscles. After a certain period both the semi- 
solid and the liquid effusion become turbid, and in fact puriform. In 
severe cases the tissues are so closely stuffed with inflammatory products 
that the veins passing through them become more or less occluded, the 
limb-segment beyond the joint is prdportionably ©edematous, while the 
smaller skin-veins are abnormally full. About this time the limb assumes 
false positions, of which more hereafter. 

The above changes occupy, giving margin for the most and for the least 
acute cases, from three to eight days. The next phases bring on augmen- 
tations of these events ; more pus-forms in the joint, the fringes of the \ 
synovial membrane hypertrophy and form arborescent," papillary, warty 
growths, which intrude into the cavity and overhang the cartilages. The 
peri-articular structures, viz., areolar tissue, capsule and ligaments, become 
softened and more or less absorbed ; the fibres of which they are composed 
are separated or changed into new soft inflammatory material ; and ab- 
scesses, not at this period communicating with the joint, form in that neo- 

1 This is hardly the place to discuss the largely ramified doctrines «of inflammation ; 
the reader is referred to the fine works of Dr. Burdon-Sanderson. to Virchow, Cohn- 
heim, Ton Recklinghausen and others. Drs. Huter and E BChm have also made 
special studies of inflammation as it affects the synovial membrane, but the impossi- 
bility of watching the process, as in transparent tissues, has prevented these observa- 
tions leading to definite results. 

2 See a beautiful specimen in the Museum of the College of Surgeons, PathoL 
Series, No. 899a. For a fuller account of these growths see Chapter VIII. 



SUPPURATIVE SYNOVITIS. 49 

plasm. Muscular contractions are no longer equable, but also spasmodic, 
the jerks occurring chiefly when the patient is falling asleep. 1 

In a few hours more the joint-cavity is filled with pus to distention, al- 
most to bursting. Cases are on record of entire recovery from this stage 
without leaving trace of the severe condition. It is therefore evident that 
disease may even reach thus far without of necessity destroying or even 
permanently affecting the cartilages ; but such recoveries ' are among the 
rarities of surgery, for at this period those structures are nearly always 
pretty deeply affected, being, like the other tissues, inflamed. The patho- 
logical anatomy of chondritis will be discussed in a separate chapter. I 
would here only point out that the parts most involved are, on both bones, 
those that have been subjected to mutual pressure ; at these places deep 
inflammatory ulcerations are frequently found, while other parts remain 
slightly or not at all affected. These ulcerations are considered by some 
pathologists as merely passive phenomena ; the view is erroneous, as a 
simple section through the edges of the ulcer, or, still better, a section 
tinged with nitrate of silver shows cell-proliferation as markedly developed, 
or nearly so, as can be found in the synovial membrane itself. In other 
parts of the joint-surface, a considerable district of the cartilage, together 
with the articular lamella, may separate bodily from the underlying bone 
and lie loose among the proliferating outgrowths from the synovial mem- 
brane and the pus in the cavity. 

The next phases bring with them rupture of that pus-secreting granu- 
lating tissue which now occupies the place of the synovial membrane. The 
pus from the joint may now mingle with peri-articular abscesses, or, pass- 
ing into previously healthy spaces, set up new foci of suppuration, and dif- 
fuse itself more and more among the inter-muscular septa or immediately 
around the bone, often at a great distance from the seat of disease. The 
cartilages being ulcerated throughout their thickness in some places, while 
in others they are shed away en masse, the cancellous structure and cavities 
lie open to the joint. This structure also suppurates and becomes carious 
in some places, granulates in others ; the result, pus or granulation, 
mingling freely with the like products of the synovitis. At this stage little 
or nothing that can properly be called a joint remains ; there is an abscess 
with walls partly bony, partly fibrous, lined by a granulating membrane, 
now pyogenic, once synovial. It is perforated in probably more than 
one place, allowing its puriform contents to mingle with other abscesses, 
more or less sinuous, in its neighborhood. Any of these abscesses may open 
on the surface, in acute suppurations, generally close to the focus of 
disease. 

If recovery, of course with a stiffened joint, now set in, it will be by 
contraction and emptying of these abscesses ; the place of the pus is taken 
by fresh granulations, which fill the cavity, while the older ones, contract- 
ing as they organize, squeeze the fluid away. At last, when the abscess is 
filled up, a sort of cicatrization occurs ; the former embryonic cell-material 
becomes at first fibrous, then osseous tissue, leading to false and true 
anchylosis respectively. The subjects both of the shedding of cartilage 
and of fibrous anchylosis, are fully discussed in other chapters ; but I must 
say here that the term necrosis, sometimes applied to cartilages cast off 



1 1 shall have occasion hereafter to show that the advent of these "starting pains " 
coincides with the spread of inflammation to the cancellous structure immediately- 
underlying the articular lamella. 
4 



50 DISEASES OF THE JOINTS. 

during the process of inflammation, is a misnomer. 1 A necrosis, or slough, 
is a dead portion of the body ; the essential idea involved in that term is 
death. The portions of cartilage separated in these diseases are quite 
healthy at the time of separation. But the bone underlying portions of the 
joint has primarily or secondarily succumbed to the effects of inflamma- 
tion ; the articular lamella is separated, and with it the cartilage of incrus- 
tation must perforce fall away. If this process have been rapid, the latter 
structure is quite healthy ; if less quick, an amount of fatty degeneration 
or of inflammation commensurate with the slowness of the process, may be 
detected. Always on examination of the deep, the hitherto-attached sur- 
face of the cartilage will be found gritty and rough, not unlike that of 
emery cloth. This grittiness is produced by the articular lamella, which 
has come away, not in its entirety, but divided into little short prisms, by 
cleavage along those wavy lines of fibrillation already described (p. 5). 
The bases of these prisms are of all shapes, from the triangle to the dode- 
cahedron. 

The production of fibrous anchylosis, and therefrom of true anchylosis, 
is in this wise : When granulations sprout from the bone-cancelli, they 
spring from the lining membrane of those cavities, which of course clings to 
the bone-lamellse. Therefore, when two sets of granulations from opposing 
bones meet, the real state is that, from the edges of one set of cancelh to 
those of another, lines of soft tissue run. These lines, though they may be 
obscured by their very softness and decussation, form a minute articula- 
tion ; while the interstices of the lattice-work are filled out with a newer, 
probably softer progeny. Yet when fibrillating contraction takes place, 
these different lines, becoming more solid, define themselves ; the meshes 
hitherto filled with embryonic cells are cleared, and become the tissue 
meshes of dense areolar structures ; thus is left an interlacing fibrous net- 
work, running from the edges of cancellar lamellae of the one to those of the 
other bone ; and, as, like all cicatrices, this material still further contracts; 
it binds the two altered joint-ends more and more tightly together. If in 
process of time this tissue ossify, the interlacing fibres become the walls of 
new cancelli, continuous, both as to their cavities and as to their parietes, 
with the older ones inside the normal bone. 

But there may be no attempt, or at least none but futile attempts, at 
these reparative processes ; then, on the contrary, increasing and continu- 
ous suppuration still further exhausts the patient, who, if he still retain the 
joint, dies, if the malady be quite acute, of exhaustion, probably combined 
with pyaemia ; if more chronic, of hectic and of lardaceous disease of the 
viscera, or other such complication. 

The few words which must here be said (the subject is treated in the 
sequel) concerning false positions of joints and subluxations have been de- 
ferred in order to leave the course of our narrative uninterrupted. Very 
little is known of the causes which produce abnormal or strained postures. 
M. Bonnet's explanation, that the limb assumes that position which permits 
to the synovial membrane its greatest capacity, is insufficient, since the 
posture assumed is frequently that which diminishes this cavity nearly to 
the uttermost. The explanation that the limb tends to the side of the 
more powerful muscles is probably correct as far as it goes, but it does not 
account for all the phenomena. Ease, that is to say a supposed instinctive 

1 There is such a thing as necrosis of cartilage, but this is probably non-inflammar 
tory ; it gives rise of itself to no symptoms, very rardy extends through the whole 
thickness of the structure, and never involves the lamella. (See Chapter IX.) 



SUPPURATIVE SYNOVITIS. ;;1 

choice of that posture which is least painful, is a quite untenable theory, 
since the most severe of these pains are only to be relieved, by entirely 
changing the position. 

The partial or complete dislocations attending this disease are the re- 
sult of some extreme malposture, or more commonly of irregular muscular 
contraction acting upon a joint whose uniting ligaments have become too 
disorganized, to resist its effects. The joints of the lower extremity, especi- 
ally the hip and knee, are most liable to these displacements ; but in one 
case of traumatic suppuration of the elbow I found the radius dislocated 
forward on the anterior surface of the humerus. At the hip-joint, when 
acute suppurative synovitis occurs, a rare event, the head of the femur 
leaves entirely the acetabulum, and lies generally on the dorsum ilii. The 
knee, when flexion has been allowed to persist, is subject to one of two 
subluxations, namely, posterior, in which the tuberosity of the tibia is 
drawn into the popliteal space, and, far less common, lateral, in which that 
bone is thrown outward, so that its inner surface receives no longer the 
internal but the external condyle of the femur. With this a certain 
amount of posterior dislocation is usually combined. 

Symptoms. — If suppurative synovitis make its appearance as a sequela 
or exacerbation of acute sero-synovitis, the change in the character of the 
inflammation is ushered in, or closely accompanied by, considerable increase 
of pain and of fever, which is often, though not always, preceded by a dis- 
tinct rigor. Then the comparatively slight symptoms of the one disease give 
place to the far graver ones of the other. More usually suppurative syno- 
vitis commences at once as a severe malady, and marks its character both 
by general and local symptoms before, probably, a drop of pus has formed 
either in the joint-cavity or in the tissues. 

A rigor, usually a pretty severe one, preceded by a certain period of 
malaise, is followed by intense pain in a joint, probably an injured one, 
which almost immediately begins to swell. Pyrexia, marked by a tempera- 
ture of 100° to 103 d , or even more, at once sets in. The kind of swelling 
differs from that of a simple synovitis, as described at p. 31. It is rounded ; 
the depressions marking the site of ligaments, tendons, etc., being filled up, 
the whole form is more shapeless, and the texture is doughy, pitting super- 
ficially on prolonged pressure. The skin, unless the joint be deep, is rather 
red or pink, not uniformly, but in somewhat foliaceous patches, most 
marked where the absorbents are chiefly abundant ; between these patches 
the surface looks white and sodden. The blush readily disappears on pres- 
sure of the finger-tip, and returns slowly. If the disease have been caused 
by a wound, the diagnosis is greatly facilitated. At the period of the rigor, 
or shortly after, the orifice, from which synovia previously flowed, unless it 
be closed and covered with collodion, or other such material, becomes dry ; 
the subcutaneous tissue pouts through the opening, and is either livid or 
unnaturally pale ; if granulations have already formed, they shrivel, and 
when the fever is fully established, entirely disappear, leaving a naked raw 
surface, with, until pus forms, a dry and harsh-looking aspect. 

The surgeon will, however, be obliged in mercy to restrict his examina- 
tion as much as possible, for by this time, viz., from fifteen to thirty hours, 
in pronounced cases, the pain will have become exceedingly severe ; the 
patient dreads any movement of the limb or even any contact ; with fright- 
ened gesture he waves off the approach of the surgeon's hand ; often, 
indeed, he will warn the attendants not to touch the bed, or beg them to 
walk softly lest they shake the room. This pain, though constant, has 
periods of exacerbation, which chiefly occur at night, when the tempera- 



52 DISEASES OF THE JOINTS. 

tare -will rise ; it is variously described as rending, bursting, or burning; 
whatever other character may be noticed, it always presents a sensation, as 
though the bones were being forced or wrenched asunder. 

In from three to five days, during which time, in bad cases, the distal 
■segment of the limb will share in the oedema, and even show a more 
marked and more superficial effusion, starting pains, an important symptom, 
of which more will be said in the sequel, commence, and rapidly increase 
in intensity, while malposture of the joint will arise. These positions are, 
of course, special to each joint ; and it is very rare to find any inflamed 
articulation vary from its own peculiar faultiness of posture : they are 
hardly marked in the joints of the upper extremity, since the forearm held 
to the side, or the rectangular position of the elbow in diseases of those 
joints respectively, offers no especial peculiarities. Suppurative inflamma- 
tion of the hip produces marked flexion of the thigh or the abdomen, with, 
at first, outward rotation and abduction ; but these two latter postures are 
often modified by the appliances, cushions, or pillows, used to support the 
limb. The most frequent position of the unassisted patient is lying on the 
sound side, with the limb of that side nearly straight, while the diseased 
thigh, very considerably flexed, is thrown over the other, and rests with 
the inner condyle on the bed. When the knee is acutely suppurating, that 
joint becomes more or less rapidly flexed ; at first moderately, then to a 
right angle, and if still unsupported and uncared for, will go on bending 
until the extreme of flexion is reached, the heel almost touching the but- 
tock. At the same time a certain amount of subluxation is commonly evi- 
denced by unnatural prominence forward of the condyles and abnormal 
retrogression of the tuberosities of .the tibia. The favorite tendency of a 
patient left free to choose his own position, is to lie with the body almost 
supine or a little turned on the diseased side, the thigh bent on the abdo- 
men, the leg on the thigh, and the whole limb rotated outward, so as to 
rest with its outer surface on the bed. Patients suffering very severely, or 
who are very sensitive to pain, either turn the body over toward the dis- 
eased side, or do not rest the limb in the manner above described ; but 
grasp it with both hands just above the knee, endeavoring thus to guard it 
against any movement or shake. The ankle thus inflamed takes a mean 
position between the right angle and the extreme of flexion. These pos- 
tures, whether, as at the knee or hip, abnormal, or, as at other joints, not 
of themselves unnatural, are very fixed, the fixity being more distinctly 
morbid than the mere position. The slightest attempt on the part of the 
surgeon to alter them elicits severe pain, and often (always if the patient be 
a child) loud screams, while the muscles, either by reflex or simply emo- 
tional contraction, resist such attempt to the uttermost. 

This fixity is always accompanied by wasting of the limb, so rapid that 
one may see the difference in size on consecutive visits. He who is not 
much accustomed to such maladies is rather apt to interpret the change of 
form as produced by increased swelling of the joint. Certainly, such cir- 
cumstance may aid, but after the third or fourth day, the appearance is 
chiefly due to the diminution of size in the limb immediately above the 
articulation. The amount and rapidity of wasting are always commensurate 
with the abnormity and fixity of posture, and afterward with the severity 
and frequency of the starting pains : the emaciation is much more quickly 
and completely exhibited in the limb-segment above than in that below the 
joint. 

The pyrexia is, as has been said, at first of the inflammatory type ; the 
thermometer, although it may rise a little at night, and slightly fall in the 



SUPPURATIVE SYNOVITIS. 53 

morning, remains very even, being in the slighter cases about four, or in 
more severe attacks, about seven degrees above the norm. In a few days, 
more or less, according to the intensity of disease, its indications change ; 
the temperature line on the chart becoming very uneven and sharply ser- 
rated ; in the morning falling below 100°, even perhaps nearly to the norm, 
in the evening running up to 104° or 105°. At the same time the pulse 
becomes small, quick, and thready, the tongue covers itself with a brown ( 
fur, chiefly at the back and along the raphe. These symptoms mark the 
approach or advent of a typhoid condition. 

The surgeon who sees his patient for the first time in this phase of the 
disease, has a very difficult prognostic problem to solve. The possibility of 
cure, with mobility intact, or but slightly affected — of cure by anchylosis — 
the necessity of serious operative measures at once or in the immediate 
future, are alternatives which present themselves for consideration. Al- 
though in all these cases the prognosis must be very doubtful, indeed grave, 
yet it must be remembered that occasionally an articulation, even so far 
advanced in suppurative inflammation as the symptoms above described 
would indicate, may, by judicious management, be led back to a healthy or 
nearly healthy state. In other cases the best that can be hoped is anchy- 
losis, either true or false. 

The elements whereon judgment must be founded are general and local. 
The former are the duration of the malady, the persistence of the starting 
pains, the intensity and mode of pyrexia. Thus a disease in which very- 
acute symptoms have only lasted from three days to a week, or longer, if 
less severe ; in which the pyrexia, high from the first, has not continued to 
increase, and more particularly if the thermometer chart do not represent 
abrupt and high waves of variability ; in which inedia and occasional pro- 
fuse sweats at night, together with slight sensations of chill, are absent, or 
nearly so ; in which the starting pains are of recent date, and have not in- 
creased in intensity and frequency ; — such a disease may still be quite capa- 
ble of cure if the local symptoms be favorable. 

Favorable local signs consist in absence or decrease of oedema in the 
limb-segment below the joint, absence of greatly enlarged surface veins, of 
increasing intra-articular fluid, or of increase either in size or color of the 
red patches in the site of the lymphatics. Of course, if to these decrease 
of one or more symptoms be added, greater hopefulness may be assured. 
But no more than a remotely probable view of the future can be obtained, 
unless opportunity for a complete examination of the joint be afforded ; 
and this is hardly possible without the aid of an anaesthetic. Such adjuvant 
will in all probability be needed merely, as we shall see, for the sake of 
treatment ; and the surgeon should seize the occasion to make, not a rough 
or too greatly prolonged, but at least a thorough examination of the limb. 
The points of chief prognostic value are the condition of cartilages, bone, 
and ligaments, especially of the two first. Even when the patient is quite 
insensible, so as to leave us at entire liberty to grasp and move the joint, 
some difficulty will nevertheless attend our attempts to form any certain 
conclusion on the condition of the cartilages. Any grating which can be 
defined as osseous is of course conclusive as to breach of substance ; but 
there are many discernible friction-symptoms easily mistaken for bony 
grating, and there are forms of cartilaginous destruction which do not 
grate ; there may even be ulcers quite through the cartilage, from which no 
bony grating can be produced, because the opposite surface is still pro- 
tected by its normal covering. Yet a joint which can be straightened or 
bent with that perfection of Motionless motion characteristic of these 



54 . DISEASES OF THE JOINTS. 

mechanisms, is hardly likely to be the seat of cartilaginous ulceration. Add 
to this, the absence, or the very recent appearance of starting pains, or of 
any strongly marked malposture, and we may conclude that the morbid 
processes have not yet produced irreparable mischief. Our further judg- 
ment of probable events, whether, namely, we may or may not reasonably 
hope for amelioration, depends upon our appreciation of the general signs 
above given, among which an almost level and not ascending thermometer, 
combined with youthfulness, are not the least important. 

If, as is unfortunately only too possible, the case do not tend to recov- 
ery, it may take one of two courses : it may continue, or even increase the 
rapidity of its course, or it may assume, though still remaining suppurative, 
a more chronic character. In the former event, the malposture, unless it 
have been remedied, becomes more and more marked ; the fluctuation of 
intra-articular fluid more evident, while a tendency toward rupture of the 
synovial membrane is usually marked by disproportionate increase of swell- 
ing in certain directions, as, for instance, at the shoulder in front of the 
joint, at the elbow just inside the triceps tendon, at the wrist between the 
ulna and common extensor tendon, at the knee over the subcrureal bursa, 
at the ankle in front of the outer malleolus. 1 Abscesses form in the peri- 
articular tissues, which may be quite without communication with the joint ; 
may have originated in rupture of the membrane, or having been at first 
independent, may afterward become part of the joint-abscess. Those in- 
dependent of the joint may form in any part of the circumference ; those 
resulting from perforation of the capsule have not only their places of pre- 
dilection as above detailed, but in their further course they often extend 
great distances ; they follow almost always the same directions, being com- 
pelled thereto by the disposition of fascise, inter-muscular septa, etc. 

Even now the limb may still be saved, though with anchylosis ; gene- 
rally true, often false. The first appearance of a tendency to get well will 
be decline of pyrexia and pain, return of appetite and sleep, while the old 
abscess-openings, now reduced to sinus mouths, discharge less and less, 
and then heal, the swelling diminishing more and more. But if the dis- 
ease still persist, increase rather than diminution of the discharge sets in, 
the one bone becomes movable on the other in abnormal directions ; as, for 
instance, the ulna and the tibia may be shifted laterally on the humerus and 
femur respectively, while a probe passed into the sinus may detect carious 
or necrotic bone ; in fact, the whole joint becomes disorganized, and the 
patient is exposed to all the dangers of hectic or pyaemia. 

Treatment. — All wounds which penetrate into a joint require the same 
form of treatment, modified only to meet the exigencies of puncture, incision, 
or laceration ; but a puncture or short incision must not at once be set down 
as an opening into the joint, even though it give exit to synovia. The pres- 
ence of bursse (not communicating) about many articulations, as, for instance, 
the knee, must be taken into account ; their position, having been already 
mentioned, requires no further description here. If, after due examina- 
tion, no definite conclusion be possible, the case must be treated on the 
worst supposition. La the first place, entire cleanliness must be ensured 
by an antiseptic injection, and I hold a three per cent, solution of carbolic 
acid, used warm, to be the best. If the opening be merely a puncture, this 
should be slowly injected with a small-nozzled syringe ; the joint should be 
filled so that at all events the fluid, when the procedure is completed, drib- 
bles out, and may be caused to flow more rapidly on pressure. After leav- 

1 The hip lies too deep to permit us clearly to define a spot. 



SUPPURATIVE SYNOVITIS. . O.J 

ing the liquid in the joint about a minute, it may be gently pressed out, 
and, if feasible, the limb so placed that the wound is dependent. As soon 
as the joint is empty, or nearly so, the puncture is to be covered with anti- 
septic gauze, and dressed secundum artem. Much the same means are to 
be taken if the synovial membrane have been laid widely open ; but since 
in such cases a quantity of gravel, shreds of clothing, or other foreign mat- 
ter, may have been introduced, the wound should be carefully examined, 
any impurity removed with properly asepticized instruments, or fingers — 
even, if necessary, a finger may be passed into the membrane to feel for 
foreign substances. When entirely cleansed, the joint should be filled with 
carbolic acid solution, sutured if necessary, and properly dressed. Now 
comes the consideration of immobilizing the limb. I have had cases of 
joints wounds which have done perfectly well upon a splint — such as that 
described in the previous chapter — also cases that I have treated by plaster- 
of-Paris with equal success. I do not think the particular appliance is of 
any consequence as long as the joint is really fixed. The gypsum has a de- 
cided drawback, for if the joint become painful, suppurate and swell, it 
may be necessary to remove the appliance at a time when every slightest 
movement causes exquisite pain. Therefore I generally use one of the 
forms of splint already described, made more completely effective by using 
a bandage soaked in a thin solution of gum, dextrine, starch or water-glass, 
leaving the wounded joint more or less accessible. With this, or with the 
simple precaution of a sufficient aperient, the patient should be left. Any 
kind of joint-wound, save perhaps the merest prick, should be immediately 
treated by ice ; at the very least, and in all cases; it should be at hand for 
prompt use, should any inflammatory symptoms commence. If suppu- 
ration arise, the treatment will be like that used in the non-traumatic form 
of the disease, and this, whether it begin at once on a previously healthy 
joint, or be a sequela of simple synovitis. 

The general treatment will begin with a rather sharp purgative, partly 
because it is well, whenever a rapid surgical pyrexia commences, to be sure 
that the primae vise are not loaded ; secondly, because it is advisable to 
have this part of the matter done with before the period of most acute pain 
commences ; thus obviating the necessity for any great amount of disturb- 
ance during that phase. From a scruple to half a drachm of the com- 
pound jalap powder, with some compound spirits of ammonia ; five grains 
or more of the compound colocynth pill ; or, in young and weakly persons, 
simply a rhubarb pill or draught, will be the formula generally advisable. 
Then, as the thermometer tends to run up, an effervescing mixture of cit- 
rate of ammonia (Formula I.) or acetate of potash with acetate and carbon- 
ate of ammonia, combined, if the pulse be full and bounding, with ipeca- 
cuanha wine, tincture of digitalis, or potassio-tartrate of antimony, will be 
the most efficacious means of lowering the temperature ; caution, however, 
must be used, lest at the same time we lower too much the patient, espe- 
cially if the last-named drug be exhibited ; and this caution applies, not 
only to the dose, but to the period of its administration ; from twenty-four 
to seventy-two hours — according to the strength of the patient — should not 
be exceeded. I also have thought that tincture of aconite in minim doses 
has proved beneficial, if used so early as to be rather a prophylactic than a 
remedy ; but the uncertainty of deduction in such circumstances need 
hardly be pointed out. After this first period the treatment must rather 
incline to the stimulant and tonic form, for, be it remembered, the malady 
is one which will call largely on the patient's strength and endurance. He 
will have to be backed up, not merely for present exigencies, but for a 



56 DISEASES OP THE JOISTS. 

rather wide future. Some form of narcotic will be always necessary, and 
there can he no doubt that, though we may occasionally be driven to such 
expedient, the worst way of administering these remedies for local pain is 
by the mouth ; the best by the subcutaneous tissues. They may also be 
given per rectum. Experience has convinced me that when hypodermic 
medication was first introduced we made too large a difference in the doses 
given by the mouth and by the skin, and that we may without danger em- 
ploy almost equal doses ; again, that if very severe pain urgently require 
morphia, it is better to give such a dose as shall surely act, than one which 
shall only confuse the patient's ideas, but not destroy the pain, and leave 
him on the morrow tired, head-aching from no sleep, or half -sleep, feeling, 
all the evils of, and no benefit from the drug. The dose for an adult must 
depend on the amount of pain. If this be moderate, one may inject -J grain 
of morphia ; £ to f grain if it be severe ; but often it is better to combine a 
drug which, besides acting as an anodyne,, stimulates the respiratory centres. < 
Thus I prefer -J- grain of morphia and -^-J-g- grain of atropine, or | grain of 
morphia with the same amount, or with a smaller dose of atropine. (See 
Formula YL.) 

The local treatment must be regulated by the condition in which the 
surgeon finds the limb. If, on his arrival, no malposfrure and no fixity of 
position have commenced, he must at once place it on a splint, or, if he 
prefer, in plaster-of-Paris, in the postures and with the precautions already 
given (p. 36). Let him, if either elbow, wrist, knee, or ankle be involved, 
swing the limb. The amount of comfort which the patient gains by this 
arrangement can hardly be overstated. If the joint have become fixed in 
some of the malpostures, described at p. 34, it is the first and most impera- 
tive duty of the surgeon to reduce the limb to a proper position. I am not 
in any way exaggerating the benefits of this treatment when I say that of 
commencing suppurative synovitis a good number of cases may be led to a 
fortunate ending if this point be at once attended to ; if it be neglected or 
overlooked, most, if not all, will end badly. Moreover, as I have again and 
again witnessed, pain which has been of the most severe and unmanage- 
able description while the joint is in malposture, will either almost entirely 
disappear or become quite amenable to moderate treatment, when the limb 
has been put into a good position. A further importance attaches" to this 
matter, namely, if the iimb be left in an awkward posture, and if, in spite 
of such error, the patient recover with an anchylosed joint, his limb will be 
very useless, unless some further surgical procedure — not always success- 
ful — be adopted ; whereas we may avoid such necessity, if, during the mal- 
ady, the limb be placed in that posture which will be, in' case of fixation, 
most convenient to the patient. To effect this re-position of the joint, 
ether or chloroform must be given, so as to induce a rather deep narcosis. 
No force will be required early in the case to rectify the posture ; even 
subluxations will, under skilful management, disappear. A splint must 
then be applied while narcosis continues. The proper splintage for differ- 
ent joints have already been described. I need only add, in regard to the 
hip, that great care must be taken that the thigh is really straight on the 
pelvis, and that no ambiguity produced by mere incurvation of the loins 
deceive us. (See Chapter XTV.) Probably some form of extension will 
afterward be desirable. 

When all this has been achieved, further local treatment requires our 
utmost care, and much will again depend on the stage of the disease : if it 
be still early, that is, as well as can be judged, before pus has actually 
formed, much may be effected by a powerful revulsion. Cantharides in 



SUPPURATIVE SYNOVITIS. 57 

any form is useless. A' line drawn on each side of the joint with a very 
hot — a white hot — iron has, in one or two instances under my care, proved, 
efficacious. Petrequin's cautery is the best instrument for this purpose ; 
or, again, the joint may be painted over with a concentrated tincture of 
iodine (Formula). 

But all these applications have this inconvenience, if they do not cure, 
or almost cure the disease, either because the phase has been mistaken, or 
because it is from its onset too obstinate to be thus eliminated, they leave 
sores and troubles behind them which add to our difficulties, and to 
the patient's sufferings. I prefer therefore, in nearly all cases, cold, a 
rather intense cold, by means of ice broken into small pieces, put into a 
wide-mouthed india-rubber bag, applied immediately to the skin, and 
changed sufficiently often ; we may even increase the cold by adding a 
little salt. The inconvenience of weight may be obviated by partial sus- 
pension ; but care must be taken that a good large surface is in contact 
with the bag. After a very few seconds — the first impact of the cold is 
often disagreeable— a decided sense of relief is produced by this application. 

If in spite of this treatment, the signs of suppuration in and around the 
joint still continue, it becomes desirable to evacuate the fluid. This may 
be done, as is sometimes recommended, by means of a trocar and canula ; 
but I do not approve this method, because a mere puncture does not as a 
rule sufficiently empty the joint, relieve the peri-articular tissues, nor give 
exit to shreds and flocculi, nor, in a late phase, to any fragments of shed 
cartilage. 

In 1851, Mr. Gay advocated free incision, 1 which, indeed, had been pre- 
viously proposed by Petit, Boyer and others, though it had fallen into dis- 
use chiefly from dread produced by the result of wounds penetrating into 
sound joints. There is, however, no real analogy between these two con- 
ditions ; a suppurating joint is no longer a cavity enclosed by a membrane, 
sensitive, as is synovial tissue, to every pyrogenous influence ; but has be- 
come simply an abscess-cavity surrounded by an embryonic tissue (pyo- 
genic membrane) analogous to, if not identical with, granulation tissue, 
and not peculiarly sensitive to impressions from without. Hence such a 
cavity may be laid open with the same safety, but also with the same dan- 
gers, as any other deeply seated abscess ; the safety lying in its indiffer- 
ence to ordinary stimuli, the danger in the tendency of pus lying in large, 
deep, and complicated cavities to putrefy, and to give rise to secondary 
troubles, such as septicaemia or pyaemia. These dangers may all be obvi- 
ated by antisepticism well and thoroughly carried out, and under this mode 
of management acute articular abscess ought to be laid open by one or 
more free incisions much earlier than can be advised, if the cavity must be 
exposed unprotected to the air. A joint which evidently contains inflam- 
matory pus, i.e., not a mere surface-secretion (p. 29) — and the diagnosis 
must depend chiefly on the systemic symptoms — ought always to be thus 
emptied when the temperature is found not to decline, more especially if 
the pain continue severe. The shoulder may be incised parallel with the 
fibres and through the front portions of the deltoid, beginning close to the 
acromion process, and terminating short of the neck of the humerus, so as 
to avoid the circumflex nerve. The elbow had best be opened at the junc- 
tion of the radius with the capitellum by a transverse incision, and if the 
size of the abscess seem to render it necessary, this simple line may be 
converted into a T incision by another along the outer border of the ole- 

1 Medical Times and Gazette, vol. xxiv. , p. 546. 



58 DISEASES OF THE JOINTS. 

cranon. The wrist may be laid open anywhere at the posterior part, but 
most advantageously by an incision along the course of the extensor min- 
imi digiti tendon. "The hip is rarely affected with acute suppurative syno- 
vitis, but when this occurs, there is great danger of spontaneous disloca- 
tion ; an early opening should therefore be made, but I am hardly pre- 
pared to advise a free incision into this deeply seated joint, though in 
severe cases I should not hesitate to do so, if a cutaneous puncture with a 
tenotome and a wide incision of the capsule should fail to give relief. At 
the knee-joint the best plan is to make two incisions, the one just in front 
of the internal, the other of the external lateral ligament. For the ankle 
an incision in front of the external malleolus, and if necessary of the inter- 
nal also, may be made. The anatomy of some joints precludes the possi- 
bility of making incisions in the most depending parts, and the after-treat- 
ment, which chiefly consists in careful washing out, is in such articulations 
doubly necessary. All suppurating joints thus treated by incision must be 
carefully syringed twice or thrice a day. The best mechanism for this pur- 
pose is Esmarch's, which I can best describe as a metal can or pot sus- 
pended some height above the bed, having at its lower part an opening, to 
which an india-rubber tube terminating in a canula and stopcock of proper 
size, can be affixed. The best fluid for washing out joint-abscesses is car- 
bolic acid — a three per cent, solution ; it is far more reliable than the thy- 
mol. The canula must be so managed as to insure contact of the liquid 
with every part of the joint. The off-drain can easily be arranged by prop- 
erly folding mackintosh sheeting so as to leave a channel or spout leading 
to a vessel on the floor. To the part, when dressed, ice-bags may be ap- 
plied outside the bandage ; or if the general condition be depressed, and 
the tissues passively congested rather than inflamed, cold may be omitted, 
or even warmth may be substituted. 

By such treatment joints thus diseased may be saved, occasionally even 
restored with their functions restrained, rather than injured. More often 
the cure is by anchylosis, of which hereafter. 

Occasionally, however, despite the most careful and skilful treatment, 
neither the joint nor the patient gets better. In spite even of incisions, 
acute suppuration may continue ; the temperature keeps high, and rises 
still more in the evening ; the tongue gets brown and dry ; the appetite 
entirely fails ; and the patient, living perhaps chiefly on stimuli, becomes 
rapidly exhausted. In such case, to save life, amputation is an unfortunate 
necessity, which, in such a bad condition of affairs, the surgeon must always 
have in his mind, watching for any signs which may still induce him to try 
and save the limb ; yet also very careful lest he postpone operation so 
long that he jeopardize its success. In other cases the violence of the dis- 
ease may have been subdued, and yet the joint continue to suppurate, and 
not the joint only, but the limb in the neighborhood and at a distance. 
Here, too, the surgeon must determine if and when amputation may be ab- 
solutely necessary, but the slower march of the disease will give him oppor- 
tunity for more leisurely consideration ; he will try whether counter-openings 
in various parts, injecting with carbolic acid, bandaging toward the open- 
ing with narrow pads fitting over the tracks of the abscess may not diminish 
the discharge and induce healing. If all these measures prove useless, and 
if he find either that the abscesses will not heal or that fresh ones continu- 
ally form, he has but the one resource, and must not too long delay. I 
would also point out and lay considerable stress on the statement that cases 
of this sort are the less hopeless if the abscesses be somewhat superficial 
Abscess among the deeper muscles of a large limb, as the thigh, especially 



SUPPURATIVE SYNOVITIS. 59 

if it run not downward but upward from the diseased joint, is of less good 
import. Worse than any other, and indicating earlier amputation, is sup- 
puration, running along the bone and extending farther and farther up the 
limb, ■with little or no tendency to come to the surface. 

I subjoin a case, to show that wounds of joints, even though no antisep- 
tics be used, are not of necessity followed by synovitis ; but by no means 
to recommend such omission. 

Case "Vlii. — On March 14, 1859, I saw H. L., a young woman upon 
whose knee a boil had that morning been so incautiously incised, that it 
was feared the joint was opened ; the circumstance leading to this suspicion 
was an escape of synovia. The boil was close to the ligamentum patelke, 
close to and running parallel with which was an incised wound, a little more 
than an inch long, from which synovia oozed, and when the leg was bent, 
flowed pretty freely. This flux proved nothing, since, although rather 
plentiful, it might be produced by the bursa in this situation. I therefore 
warmed, oiled, and carefully introduced a thin probe, when it sank at once 
to a depth clearly showing it to have entered the knee. The instrument 
was withdrawn, a gutta-percha splint placed on the limb, and the wound 
closed by painting its surface with collodion, and covering it wdth a piece 
of soap plaster ; the object being not merely to prevent the entrance of air, 
but also the exit of synovia, which would tend to keep it open. The wound 
healed without a sign of synovial inflammation. 

The next case shows that even a permanent opening may exist without 
accompanying synovial affection. 

Case IX.-~Henry Short, sailor, aged thirty-two, was sent to me on April 
25, 1859. 

He came for ulcers about the right elbow, of which he gave the follow- 
ing account : Three years ago, while at sea between Madras and Calcutta, 
there broke out on board ship a complaint which he called scurvy-boils. 
Several of the crew were affected. He had several boils on different parts 
of his body, the worst being about his elbow, and nearly a fortnight after 
they had opened into an ulcer, the bone began to get bare. On his arrival 
at Calcutta he went into hospital, where the sore healed ; he says that no 
bone came away, but in this he must have been mistaken. 

There was a large scar, with uneven edges at the back of the elbow, 
upon which four small ulcerations had reappeared — one in the centre being 
deep and fistulous. Around this spot the elbow was deformed by a depres- 
sion, which, judging by eyesight, merely appeared to result from absence 
of bone. On examining the part more closely by touch, it was evident that 
a portion of the olecranon was absent ; the part still remaining being at- 
tached like a sesamoid bone to the triceps extensor tendon ; between that 
detached piece and the rest of the ulna was an interval corresponding to the 
depression above mentioned, and which varied from three-quarters of an 
inch, when the arm was straight, to one inch and a quarter when it was 
bent, and even to nearly two inches when the cubit was strongly flexed. In 
the centre of this space was the fistulous ulcer already described, out of 
which synovia flowed freely. When he alternately bent and straightened 
the arm rather quickly, air was sucked into, then driven out of this open- 
ing, with an evident impulse ; and at the same time the synovial sac was 
first separated from, afterward propelled against, the bones of the joint, 
making a flapping noise, like the dry valve of a pump before the water has 



60 DISEASES OF THE JOINTS. 

risen. When he had continued this action some time the joint looked a 
little swollen, and on pressing it with the hands, air could be expelled from 
the synovial sac. The man experienced no pain nor any stiffness of the 
joint, and seemed surprised when told to keep it at rest. 

The treatment was simply rest, closure of this opening by adhesive plas- 
ter, and the internal use of iodine. The ulcers gradually healed ; that lead- 
ing into the joint hardly slower than the others, because all flow of synovia 
was prevented. On May 30th he was well, and about to start on another 
Indian voyage. 

August, 1860. — This man returned : the ulcer into the joint was again 
open, but no inflammatory symptom has shown itself. 

Case X. — James P., aged sixteen, fell while carrying a bottle down 
stairs, and received from the broken glass a severe wound on the inner and 
back part of the wrist. He came at once to Charing Cross Hospital, June 
3, 1872. A piece of glass was extracted by the house-surgeon from very 
deep in the wound, which was sewn up and dressed with plaster ; the boy 
being dismissed with his hand on a proper splint. On the 5th he came 
back early in the morning. The hand and lower part of the arm were much 
swollen ; the wound was inflamed, white at the edge, and nowhere united. 
On removing the dressing, some pus, followed by turbid synovia, flowed. 
He was admitted, and an ice-bag applied. I saw him later, and found him 
in great pain ; the thermometer marked 101.3° ; his tongue was coated ; 
skin dry. No action of the bowels for three days. An enema was ordered ; 
support and stimulus, and the ice to be continued. 

June 6th. — This morning he had two severe rigors and the wrist became 
more swollen and baggy ; temperature, 102.1°. Two deep incisions were 
made along the outer and inner posterior aspect of the wrist ; the dresser 
receiving directions to syringe out the wound with the permanganate of 
potash solution night and morning. He had ten grains of quinine at once, 
and five grains every six hours. 

June 8th. — The wounds were discharging freely a rather dark greenish, 
thick pus, with occasionally a streak of blood ; the swelling extended about a ' 
third up the arm ; temperature, 102.8°. He had now six ounces of brandy 
per diem, mixed sometimes with a yelk of egg ; strong beef-tea, and other 
support. 

June 11th. — The swelling had receded from the arm, but at the wrist was 
strongly marked ; all the tissues were soft and boggy. On any movement 
the carpal bones were felt to grate loosely, and, on passing the finger into 
the wound, could be felt bare and rough. A consultation with my col- 
leagues was held, which ended unanimously in the rejection of excision, 
since in the state of soft parts it would be likely to lead to some form of 
blood-poisoning. I therefore amputated as near the hand as possible ; the 
loss of the suppurating joint caused immediate improvement,* and the boy 
made an excellent recovery. 

On examining the parts removed, the radius was found bare and rough, 
a large part of its cartilage was separated from the bone, but only in part 
ulcerated, the rest remaining attached to the still adherent portion. The 
carpal bones, except the trapezoid, were soft ; some were granulating, others 
simply necrosed ; the cartilages of most of them lay loosely in the abscess- 
cavity. The synovial membrane had lost all its peculiarities, and was sim- 
ply a mass of more or less unhealthy granulations ; the bases of the meta- 
carpal bones were sound, except that of the ring finger, which was bare and 
carious. 

Case XI.— Master G., aged ten, in crossing Bond Street, was knocked 



SUPPURATIVE SYNOVITIS. <)1 

down by a Brougham-horse with such violence that he was thrown under 
the wheel of a Hansom cab, that went over his bare knee ; he wore knicker- 
bockers. This happened on July 14, 1878, about the middle of the day. 
He was at once taken to the lodgings of his friends, and I saw him within 
ten minutes of the occurrence. I found a deep wound on the inner side of 
the patella — that bone was pushed upon the outer condyle, and partially 
turned round, so that I could see a portion of thexartilage ; the wound was 
full of dirt. I had chloroform at once administered, and, under a spray of 
carbolic acid, cleaned with the same lotion all parts of the wound, passing 
my finger within the joint to remove remnants. The patellar subluxation 
reduced itself on bending the knee. I put in a drainage-tube, sewed the 
wound close, and placed the limb on a Maclntyre splint, dressing the wound 
with gauze. 

July 16th. — The dressings removed under the spray. A good deal of syno- 
via had moistened the dressings : with the exception of where the drainage 
tube passed, the wound had closed ; here lay a clot of blood looking per- 
fectly fresh and pure. The drainage-tube was shortened to about a quar- 
ter of an inch, so as not to lie in the joint ; dressing reapplied. The tem- 
perature had been 99.4° in the morning, 99.8° in the evening, so little pain 
that no morphia had been given. 

July 19th. — Wound dressed again ; drainage-tube quite removed. 

July 22d. — The wound had quite healed ; there was perhaps a little extra 
synovia in the joint. 

August 18th. — There has been nothing to report ; the slight swelling of 
the knee lasted about a week after last report — to the 28th or 29th ultimo. 
The splint was kept on another week — to the 6th August — at that time 
measurement showed no difference in the size of the two joints. I allowed 
some cautious movement, but let the joint be confined nearly straight in a 
thick leather splint at night. At the date above given the youth was walk- 
ing well, but I did not allow much exertion. 

I saw him in November ; the knee was perfect. This case, where anti- 
septics were used, contrasts strongly with the former. 

I also give a case to show that such remedies will avail even when some 
suppurative action has already commenced. 

Case XH. — Eobert P. was admitted, under my care, about 11 p.m. of De- 
cember 16, 1879, having a punctured wound inflicted by a knife during a 
brawl ; the man was very drunk. The wound was not considered by the 
house-surgeon to have penetrated the joint, but in consideration of its 
proximity to the synovial membrane the limb was put on a splint. I did 
not see the patient till the visiting time of Friday the 19th. The man then 
complained of a good deal of pain ; he had a rigor about 11 o'clock the same 
morning ; temperature 102.2°. The wound, which was about half an inch 
long, was gaping ; its edges pouting, flabby, and pale ; knee rather swoUen. 
On pressing with my two hands on the sides and back of the joint, a puru- 
lent fluid flowed, and with the last drops so much air as to make rather 
large bubbles issue from the wound. With a large glass syringe the whole 
joint was filled with a carbolic acid solution three per cent., and then 
dressed antiseptically. Some swelling and pain continued for about a week, 
but nothing to be compared to that he had before the injection ; the tem- 
perature went down, and has since remained normal. He was discharged 
cured on February 27, 1880. 

Case XHI. — Louisa S., twenty-four years of age, had been out of health 



62 DISEASES OP THE JOINTS. 

and feeling generally ill for between two and three months. Three nights 
ago she was awakened by great pain in the knee : it was swollen ; she thinks 
she sprained it a week before (such post-faeto recollections are very worth- 
less). She was admitted into hospital under my care March 10, 1875. The 
knee was very considerably flexed, greatly swollen, pitting slightly, and fluc- 
tuating, the patella knocked, but there was also much peri-articular tumefac- 
tion. It was difficult to obtain a fair examination, as the patient shrieked 
even at the approach of a hand. The tongue was furred ; temperature, 
102.6°. She says she has had no sleep for three nights ; has eaten noth- 
ing, but is very thirsty. Chloroform was administered, the knee put into a 
nearly straight posture, an ice-bag ordered to be applied ; hypodermic injec- 
tion of morphia half a grain every night, and if pain were urgent a quarter 
of a grain at any time ; the effervescing citrate of ammonia every four hours. 

March 12th. — The patient had not progressed. She was in father less 
pain for a few hours after splintage of the limb in good position, but this 
alleviation was transient. At above date the joint was more swollen, fluc- 
tuated, plainly pitted, was red on the inner side in two or three blotches, 
and in one on the outer — temperature, 103.2° ; pulse small and quick, 110. 
She begged that something might be done for her relief. I laid the joint 
freely open by an incision on each side ; the inner and longer one passing 
from above the patella almost to the tubercle of the tibia : the one on the 
outer side farther back, about two inches long and about an inch in front 
of the head of the fibula. Through both these cuts abundance of pus, mixed 
with flocculi, came away. This was done antiseptically ; the joint-bag being 
washed out with carbolic acid, and dressed with gauze. 

March 14th. — Suppuration very considerable, hardly any pain ; evening 
temperature, 101.2°. A portion of cartilage, about the size of a three-penny 
piece, softened, fibrillated and sodden, came away. 

March 20th. — The joint was much less swollen ; the infiltrated and pit- 
ting condition was less marked, and the upper end of the inner wound was 
granulating and contracting. In order to keep the outer wound, the most 
depending one, freely open, a director was passed in, and the commencing 
adhesion broken down ; some additional drops .of pus flowed. The patient 
was feeble — temperature, morning, 99.1°, evening, 101.7° ; sweats at night 
a good deal. She had been taking sulphuric acid and cinchona ; had all 
possible food and support. 

The case was long, and the possibility of saving the limb sometimes 
doubtful, but about April 25th her powers greatly improved, the discharge 
having gradually ceased, and the wounds healing ; the joint was evidently 
disorganized, and anchylosis the best termination. On May 13th, I tried 
passive movement — there was no grating. I ordered motion every day in 
order to increase the arc, which was very small The wounds were by this 
time merely short lines of granulations. 

June 17th. — But little further mobility had been gained by passive mo- 
tion. I had her taken to the theatre, chloroform administered, and en- 
deavored to set the joint free. After gaining a little more in the direction 
of flexion, I found that to continue this movement would produce too loose 
a joint laterally ; enough, however, had been gained to make the limb very 
manageable. 

July 4th. — Discharged with a healed joint, movable through an angle of 
about twenty-five degrees ; it never can be quite straightened. 

June, 1878.— This patient called at the hospital. The knee was sound, 
and with perfectly free movements within the above limits. She had 
learned to walk with a barely perceptible limp. 



CHAPTEE IV. 

ON PYEMIC JOINT DISEASE, AND ON CERTAIN OTHER AFFECTIONS 
ORIGINATING IN ABSORPTION OF MORBID MATTERS. 

Hitherto we have studied inflammations, varying in character somewhat 
among each other, but all with this peculiarity, that they are distinctly lo- 
cal ; that whether or no their origin be traumatic, they are independent of 
any blood disease. It now becomes our task to examine certain classes of 
malady produced by and dependent upon changes which have taken place 
in the blood. These, though rather a symptom than a disease, require at 
all events so much notice as will suffice for their recognition and compre- 
hension. Constitutional taint, inherited or otherwise, such for instance as 
gout, rheumatism, struma, have all a tendency to affect the joints ; and these 
will become the subjects of inquiry hereafter. Besides these inborn vices 
of the system, others, accidental and acquired, influence the blood in such 
wise as to produce a well-marked pyrexia, with which affections of the joints 
are often combined. Among these the most important are diseases caused 
by the action of pus or septic matter introduced into the system. Pyaemia 
and septicaemia, generally arising in connection with an external wound, or 
after childbirth, take the first rank among these ; but in the same category 
belong gonorrhoeal rheumatism, improperly so called, also the synovitis, 
arising in the course of enteric fever, dysentery, small-pox, and scarlatina. 
All these are connected with suppuration and breach of surface, while in 
measles the connection is scarcely more occult. 

The appearances after death of one, who, for instance, having sustained 
wound or injury, dies, after some hours or some days, of septic fever and 
exhaustion, are different chiefly according to the rapidity of the disease. In 
the slower cases abscesses, often termed metastatic, form in different parts 
of the body ; in the more rapid cases this does not always take> place. The 
latter form of disease is termed by many authors septicaemia (septhsemia of 
Virehow) as distinctive from pyaemia. 1 I regard the difference only as one 
of degree, and the cause of non-appearance of abscesses in the former mere- 
ly as want of time for their formation. If, then, an autopsy be made on 
one who dies of rapid blood-poisoning (septicaemia) in from seventy hours 

1 The various meanings given by different writers to the terms septicaemia and pyae- 
mia would render my text doubtful unless it be distinctly explained, that by the for- 
mer term I intend to designate a more rapid disease. It would be impossible in a 
work not consecrated to this special subject to dilate upon the various theories as to 
' doses of the poison, non-infective qualities of the blood taken from animals dying of 
the former disease, and of absence of bacteria in that blood. The reader desirous of 
further information is referred to the writers quoted in the text to Koch's Untersuch- 
ungen fiber die Aetiologio der Wundinfectionskrankheiten, and to the Report of the 
Pathological Society. 1879. The text makes clear my views, that the difference is of 
degree rather than that of kind, and I hold that Koch's injected miie bear out this 
idea, while with some other conclusions, both of that experimenter and of the Path- 
ological Society's committee, I cannot agree. 



64 DISEASES OF THE JOINTS. 

to a week after the first rigor, there will be found, around the place of in- 
jury, infiltration of the tissues with ichorous or foul purulent fluid (where- 
of further mention will be made), and one or more of the smaller veins 
leading from the part may be found plugged with loosely formed red, 
sometimes brownish or grayish clot. In distant parts, internal organs or 
tissues of limbs, often very little is found. The spleen is very generally 
large, soft, and easily broken down ; and save in cases of very swift death, 
red and hardened wedge-shaped patches (" blocks ") are present — the wedges 
having their thin edge turned to the centre, their bases toward the peri- 
phery of the organ ;• the liver, too, is somewhat congested and friable. The 
intestines healthy, unless there have been diarrhoea, in which event the 
glands chiefly of the large intestines, will be found swollen and red ; the 
peritoneum is generally inflamed. The blood, when one can collect it, is 
found not coagulated, but as it were inspissated, dark in color and thick in 
consistence, reminding one of pitch. Besides these appearances, one occa- 
sionally finds, on mucous and serous surfaces, spots of purpura-like extra- 
vasation. 

All this, which has nothing to do with joints, has appeared to me neces- 
sary as one aspect of a malady, in which joints are always affected, viz., the 
slower forms of the same blood-poisoning. If, instead of so rapid a case, 
we have on the table one who survived the first attack of the disease from 
forty-eight hours to ten or twelve days, we find, beyond the changes above 
described, secondary or metastatic abscesses in several places, external or 
internal, in the lungs, liver, spleen, sometimes in the kidney. Mixed with 
these are more or less frequent hardened congestions or infarctions, the 
centre of the older ones breaking down into pus. The serous membranes are 
reddened in blots or patches, and usually contain a quantity of muddy se- 
rum, or simply pus. Often, in the cellular tissue, in deep places among the 
muscles, abscesses will be found, and generally more than one joint con- 
tains pus. Of the condition of these joints I prefer to speak farther on ; at 
present it will be well to confine myself to other features of the disease. 

The wound, the neighborhood of a necrosis or of the perimetric tissues, 
as the case may be, is found darkly congested and infiltrated with sanies 
or foul pus ; and some of the veins leading from the place are frequently, 
but not always, clogged with clots, some of which may be dark in color, 
others gray and granular, some broken down, and in their interior puru- 
lent ; such thrombi have often an evil odor, and appear more or less putres- 
cent. It has been pointed out that the clot plugging a smaller vein pro- 
trudes its end into the blood-current of the larger stem into which it opens, 
and that such end is often broken down, split up into loose fibrils and 
detritus. ' 

Such finds have led to the theory that pyaemia and ite secondary abscesses 
or infarctions are merely embolic phenomena ; that little shreds from the 
thrbmbus, falling into the circulation, are carried to distant organs, where 
they plug capillaries, giving rise to blocks, congestion and suppurative in- 
flammations. That such events may occur in connection with pyaemia is 
more than probable, but they are only complications, not the essence of the 
disease. Mere mechanical obstruction will account only for a few of the. 
phenomena. In a large proportion of cases the lungs, where venous em- 
boli ought chiefly to lodge, escape altogether, while in the area of the sys- 
temic circulation many secondary abscesses are found. Again, we do not 
in pyaemia meet with unequivocal symptoms of mechanical obstruction, such 

1 Callender on Pyaemia in the System of Surgery. 



ON PYiEMIO JOINT DISEASE AND OTHEB AFFECTIONS. 65 

as gangrene, cerebral paralysis, etc. 1 Lastly — tout this evidence is merely 
negative — many cases of pyaemia occur in which no blood-clotting can 
be found in the veins leading from the wound ; '' although I am bound to 
say — and it is a matter of very great importance — that even in such cases 
the tissues around that wound present a condition of unhealthiness evi- 
dent to the naked eye, but more especially patent to a high power of micro- 
scope. 

Another condition of the wound and its neighborhood, and one of greater 
importance, is the presence of minute organisms, which crowd in countless 
numbers the exudation fluids. Several diseases, both of man and animals, 
are accompanied (produced ?) by the development of minute creatures, viz., 
in the human subject, besides pysemia and erysipelas, 3 we find them in vac- 
cinia, small-pox, enteric and relapsing fever. It is also more than probable 
that future observation will detect them in certain allied diseases of infec- 
tive origin, viz., diphtheria, scarlatina, measles, and perhaps some others. 
Two points must be especially noted. Firstly, whatever part these organ- 
isms play in the propagation of disease, or in the conveyance of infection, 
resides in the bodies themselves, and in their spores or germs, and is not 
shared by the liquid in which they float ; for when strained through a filter 
of adequate fineness, viz., baked clay-cells, the fluid is quite innocuous (see 
the experiments of Klebs). Secondly, these bodies or their germs convey 
only the malady to which they are related ; germs derived from relapsing 
fever will not produce vaccinia or enteric fever. Thus all diseases of specific 
character, such as small-pox, vaccinia, and so on, presuppose in each in- 
stance the existence of a previous case which hatched and sustained its 
special organism. 

But other forms of minute particles with which we have here more to 
do are less specific in their nature ; their appearance in the human or ani- 
mal economy does not of necessity connote the pre-existence of a like dis- 
ease. They seem more distinctly associated with the earlier stages of putre- 
faction, multiplying in organic fluids dead and outside the body, portions 
of which liquid may dry, and the particles previously suspended in it, or 
their germs and spores, be disseminated through the air, forming part of 
that dust which we may see in the sunbeam or gather from the walls and 
furniture of our living rooms. A little of this dust introduced into a prop- 
erly prepared organic infusion ' rapidly generates numberless bacteria, and 
again, with the development of such forms, putrefaction of the liquid is con- 
stantly associated ; we may indeed say that in the absence of such develop- 
ment putrefaction is impossible. 5 

1 Panura in Virchow's Archiv, Bd. xxv. 

' This failure to find the venous thrombi has occurred to me more than once, as 
also to other most careful observers : see especially Heiberg, TJeber die pyamische und 
puerperale Prozesse, pp. 20-22. 

3 The presence of micrococci in erysipelas is frequent, if not constant. On a sub- 
ject so difficult no definite opinion should be expressed unless something amounting to 
proof can be offered ; therefore I can only say here that my investigations at present 
tend to the view that in pysemia the living contagion passes into the veins, in erysipelas 
into the lymphatics. 

4 Or into a certain chemical "cultivation liquid." Burdon- Sanderson, Brit. Med. 
Journ., 1875, vol. i., p. 70 : " Half per cent, of potassic phosphate and magnesic sul- 
phate with a trace .of calcic phosphate, and then adding as required a further percent- 
age of amnionic tartrate, and of course boiling the liquor." 

6 It is only fair to state that Dr- Bastian has shown, I believe, conclusively, since the 

results are acknowledged by Drs. Sanderson, Gothmerdlen, Loppeseyler, and others, 

that certain infusions boiled for five or even ten minutes in a tube, and hermetically 

sealed during ebullition, will, if kept in a certain temperature, develop bacteriae. Whether 

5 



66 DISEASES OP THE JOINTS. 

The minute creature, hitherto, called a bacterium, is, however, by no 
means always a little stick or rod ; the microzyme, micrococcus, or what- 
ever we may call the organism, may be a rod or a spheroid, and these may 
aggregate into a " bacterium filament," or a " dumb-bell," or a " chain," by 
addition of rods end to end, of two or more spheroids in line ; even more 
complex unions are formed by a " colony " of both rods and spheroids kept 
together by a gelatinous medium. The governing forms in all these are 
the rod and the spheroid, the former from -g-J- ¥ to yoVo of an inch long, the 
latter about y, 1 ^ of a line in diameter or smaller. 

Careful and manifold experiments have shown that some of these spores, 
which, be it remembered, appear as the progeny of atmospheric dust, and 
in their separate state are ultra-microscopic, introduced into the tissues or 
into a serous cavity of an animal, multiply there, and, passing into the 
lymph and blood, produce well-marked fever ; the liquid, or rather the 
bacteria and germs in the liquid, are "pyrogenous." Moreover, if some 
of the exudation fluids be taken from that suffering animal and introduced 
in like manner into a sound creature, that one will be similarly but more 
violently affected, and so one may go on to a third and fourth animal, in- 
creasing, not in a perfectly regular manner, but still increasing the intensity 
■of the artificial peritonitis and pysemic fever. 1 The animal, after death, is 
found to have other serous membranes, besides that employed as the re- 
cipient, inflamed ; also enteritis, lung-consolidation and, if it have lived long 
•enough, secondary abscesses in liver, lung, and system ; all the exudation 
liquids and the blood itself are vibratile with bacterial movement. 

We may now juxtapose with these experiments the symptoms during 
life, and more especially the appearances after death from pyaemia in the 
human subject, and sometimes find the same organisms in the exudation 
liquids in the secondary abscesses, even in the blood of our patients. We 
may go still farther, and find that the venous thrombi, before mentioned 
(p. 64), are but crowds of bacteria held together by colored blood-plasma ; 
that the clot, probably, is produced by the organisms, is not first formed 
and then entangles the bacteria in its meshes. Furthermore, we may see 
in hospitals where an epidemic of pyaemia reigns, that although, as just 
stated, the presence of these forms in the human body does not of necessity 
denote the pre-existence of a like disease in another person, yet the malady 
is infectious, is, indeed, often conveyed from one individual to another, and 
the disease appears to gain strength as one patient takes it from a prede- 
cessor, just as the series of experimental animals adds each its increment 
of virulence to the poison. Patient No. 1 may have an open wound in such 
condition as shall nourish some of the atmospheric dust, that may fall upon 
it into the bacteroid poison, absorb it, and suffer pyaemia ; his evacuations 
being infinitely more crowded with germs than the adjacent atmosphere, 
form a new and more potent centre of infection for all other wounded 
patients in his neighborhood. 

Nay, more, I think, we may conclude that certain of these forms are 
either more pyrogenous, or that they inhabit more completely decomposed 
fluids, i.e., their presence produces more complete putrefaction than others, 
their movements are more active, and they are present in greater numbers ; 

or no this fact will bear the interpretation that he puts upon it, is a subject that would 
lead us too far from the matter in hand, as likewise would the controversy between 
him and Professor Tyndall. I need only say that the general conclusion of science 
seems to be that certain forms resist a temperature, unless prolonged, which destroys 
all other forms of microcosms. 

1 Keport of Medical Officer of Privy Council, New Series, No vi. 1875, p. 69 etftq. 



ON PYMMIC JOINT DISEASE AND OTHER AFFECTIONS. 67 

that is to say, they multiply more quickly, and are much more lively and 
active. 1 

Here is a wide field for induction, even for some speculation. In the 
experiments above referred to, a certain virulence of poison, i.e., a certain 
plenitude of bacteroid forms in active movement, is always, in the same 
genus of animal, followed by a proportionate ratio of fever ; but of two or 
more patients with the same sort of wound and treated in the same way, 
one will suffer the severest form of poisoning and die in forty hours ; an- 
other will have swollen joints, many abscesses and a long illness, from 
which he may or may not recover ; while a third, after one or two rigors 
and a high temperature, may be well in three days. In the exudation 
fluids of the first, active rod-shaped bacteria and vibrios will be found, in 
those of the second and third only a few sluggish spheroids and dumb- 
bells may be discoverable. Therefore, if all these men have been subjected 
to the same infection, we must conclude that the one form of micrococcus 
• may, under certain circumstances, generate the other. Jn the first case 
spores or germs found a fitting cultivation fluid, not merely in the wound- 
secretion, but in the blood of the sufferer, and rapidly propagated a lively 
and productive brood. The fluids of the second, in a less receptive state, 
permitted less active multiplication ; those of the third a still slower de- 
velopment. Or again, the two last or the last alone may be credited with 
some power of excretion, adding a further protective power against this 
form of infection. The clinical fact, so often witnessed in ill-regulated and 
py£emia-stricken wards, that different patients, similarly situated in all ex- 
ternal circumstances, are affected in such various degrees, appears open to 
no other interpretation, if we accept the light of experimental pathology. 

The result, then, of combining experimental and microscopical research 
with clinical observation, is that septic poison (which I hold to mean infec- 
tion by micrococci or their emanations) is administered by nature in dif- 
ferent doses and in various degrees of strength. The septic materiea morbi 
is probably but one in kind. The variety in the effects is due in part to 
the intensity of the poison, but probably more to the receptivity of the in- 
dividual (the state of his fluids). We know that certain persons are more 
prone to this poisoning than others ; also that certain conditions of body 
render any one, not previously prone, very sensitive to septic influence. 

Such is the probable history of the origin of pyaemia, in most cases of 
open wound or childbirth, surrounded by a more or less vitiated atmos- 
phere, or subject to the intrusion of unclean fingers and infected dressings. 
The presence of bacteroid germs in the air and in the dust has been pretty 
closely demonstrated by Pasteur, Klebs, Sanderson, Tyndall, and others ; 
the door for their admission into the system stands wide. But we must 
not let the simplicity and apparent completeness of. the narrative mislead 
us, for it will not account for all occurrences, for cases of pysemia without 
external wound, for its idiopathic forms, for its arising in connection with 
osteo-myelitis and other diseases, in which no means of ingress for bacteria 
exist. "We know that in these cases the exudation fluids are as much 
charged with microzymes as when we may trace them to a wound, but the 
means of their advent is unknown. On this point experiments on animals 
serve rather to increase obscurity. In sensitive creatures, as guinea-pigs, 



1 Dr. Sanderson computes that of one of the more active forms " every bacterium 
must produce 16,777,220 individuals in twenty-four hours. Putting it otherwise, the 
progeny of a mass of bacteria weighing t,-, 1 -, 7 of a grain would, at the end of the clay, 
weigh a pound." — Brit. Med. Journal, 1875, vol. i., p. 70. 



68 DISEASES OP THE JOINTS. 

or rabbits, an intense peritonitis was excited by injecting iodine, or diluted 
liquor ammonia, previously boiled to free it of any germs, with a syringe 
similarly treated, and in every instance it was found that the exudation 
liquids collected from twenty-four to forty-eight hours after injection were 
charged with bacteria, 1 and the fluid thus charged served to excite intense 
blood-poisoning when injected into another animal. 

The object of this work will hardly be served by endeavoring to trace 
the origin of the bacteria produced in such experiments, nor in the cases 
of human unprovoked pyaemia. It is certain that in man the pus of ordi- 
nary abscess of ulcers, etc., is free from microzymes, nor is their develop- 
ment to be induced so easily, as in guinea-pigs, rabbits, and other crea- 
tures very sensitive to infective disease. When the health is depressed, a 
part of the body long subject to suppuration, or the action intense, espe- 
cially when bone is the tissue inflamed, bacteria, whatever their origin, do 
undoubtedly develop, and with their development comes pyaemia, poten- 
tially or actually ; yet, occasionally, as shown by Billroth, 2 abscesses, whose . 
whole course and development are quite innocent, have been found crowd- 
ed with bacteria at the very moment of their exposure to the air. 5 Nor, 
again, must we lose sight of the fact that occasionally cases occur, in which 
no evident connection can in the autopsy be found between organisms in a 
wound and pyaemia. The ^postponed examination, necessary in dealing 
with the human subject, gives ample time for the development of low or- 
ganic forms in open wounds after death, or during a prolonged act of 
dying ; and I know by experience that in many bodies, death having been 
in no wise pysemic, we may, at the time when the post-mortem is made, 
find numbers of microzymes even in closed bags such as the pericardium. 

Thus, though all facts point most strongly to the conclusion that 
pyaemia is closely related to that form of putrefactive fermentation within 
the body which is combined with the development of minute forms of low 
organic life ; yet, as the above cautions will show, we must not hastily con- 
clude, that all and every part of the mystery is already solved by these 
recent discoveries, concerning the relationship between putrefaction and 
bacteria on the one hand, and the very frequent connection of these forms 
with septic disease on the other ; that microzymes may exist in some 
fluids within the body, and yet pyaemia be absent, is certain, and it ap- 
pears equally certain (Koch) that septic disease may destroy life, and yet 
no bacteria be detected. 

After death from this very fatal disease the joints affected are generally 
found perfectly free from inflammation, if inflammation of a vascular part 
connote active hyperaemia and tissue-thickening. Sometimes pus is found 
in the cavity, sometimes merely the normal amount of healthy synovia. 
The pus, when present, is usually creamy, somewhat viscid, but smooth 
and homogeneous. It is sometimes rather dark, as though stained by 
mixture with a small quantity of some deeply colored material. Occasion- 
ally, it has some evil odor, hardly putrefactive, but allied to that state. I 
have occasionally found micrococci in this pus, but also have failed to do 
so. The leucocytes are frequently broken down, their contours are irregu- 
lar, and the broken cells are crowded with quantities of microzymes and 
spores. 

1 Report of Medical Officer to Privy Council. New Series, No. vi., p. 71. 

2 Die Micrococcen, etc., Langenbeck's Archiv, vol. xxii. , p. 3. 

3 Dr. Heiberg (Die pyamische und puerperale Prozesse) says that " we must always 
consider these forms as coming from without." With this, as will have been seen, all 
facts do not agree. 



ON PYEMIC JOINT DISEASE AND OTHER AFFECTIONS. 69 

When the joint contains merely the usual quantity of normal synovia, 
the peri-articular tissues are more involved than is the case when pus is in 
the joint. These tissues may, without hyperaemia, be bathed in a large 
quantity of serum or of pus ; tendinous sheaths in the neighborhood of af- 
fected joints are more especially liable to pus-deposits. I have often found 
these cavities filled with such fluid, while the joint itself has been free. 
Sometimes the peri-articular and tendinous tissues are hypersemic, and 
there is something peculiar in the mode of injection of these parts ; the 
tint is not the ordinary bright red of inflammation, but is of a dusky, rather 
lurid color, and is especially remarkable in being patchy. In a small space 
of the section, big as a florin, one may find from two to seven or eight 
patches, from the size of a silver threepence to that of a split pea (the 
larger sizes are less common), marked by a deep purple coloration, the 
surrounding tissue being hardly deeper in tint than normal In these 
patches the tissues are softened and friable. Such blot-like condition is 
also characteristic of any hypertemia which may, as a rarity, affect the syno- 
vial membrane. Later on these patches become foci of suppuration, or 
rather, I would say, of " pus deposition." 

That word leads naturally to a consideration of how pus comes into a 
joint-cavity, a tendinous sheath, or the meshes of areolar tissue, without 
producing or apparently being produced by any inflammatory act. The 
question admits of many answers, none of which are quite satisfactory, and 
certainly none are proven : perhaps with our present means of investiga- 
tion no solution of the subject admits of direct proof. I think, at all events, 
the idea that pus is absorbed from one part of the body as an entity, and 
is deposited in that identity, in another cannot be sustained. It is this 
idea, however, which originated the term metastatic abscess, a term which 
had better be discontinued. Volkmann speaks of the pus-deposit as a puru- 
lent catarrh ; and in spite of his acknowledgment that the tissues are not 
inflamed, i.e., are neither reddened nor swollen, says that the pus is formed 
mi loco, as a catarrhal secretion. 

My own strong conviction is that the pus-corpuscles found in pysemic 
deposits are leucocytes, which, altered by the ingress into them of bacte- 
roid germs, 1 have emigrated from the venous radicles, because that change 
has caused them to conglomerate within the vessels, to form minute thrombi 
or blocks, and to adhere to the vascular walls, producing stasis, which fails 
to be inflammatory, not only because the vessel and tissue changes of that 
process are absent ; but also because the blood-changes, however marked, 
are different in kind. The liquor puris is identical with blood-serum. The 
materia], therefore, which is deposited from the vessels which we find in 
various cavities, and justly term pus, consists of septically altered leucocytes, 
suspended in a proportion of serum less than they floated in, while still 
circulating in the vessels. The attempt, therefore, so often made, to discover 
small quantities of pus in the blood is vain. Abstract the red disks, and 
the only difference between blood and non-inflammatory pus will be the 
larger ratio of the serum to the leucocytes. 1 In Case XVI., the blood, as seen 
in the transparent vessels of the meninges, was yellow, like thin pus ; a 
condition termed leueocytosis. Under the influence of any check to circula- 
tion, be it the impaction of a thrombus or zooglcea, or some other mechan- 
ical obstruction, this deteriorated blood leaks from the vessels into the 
tissues or into cavities ; and as smaller channels are more likely to be thus 
blocked than larger ones, so are those parts, which possess minute tortuous 

1 The usual broken condition of the pus-corpuscle is to be remembered. 



70 DISEASES OP THE JOINTS. 

capillaries, most likely to be the seat of such outflow ; therefore organs like 
the lungs, liver, kidneys or joints are especially liable to suffer from pysemic 
deposits. Now the blood, changed in the manner just described, comes out 
of the vessels in its entirety. Most of the few red disks also extravasate, 
and decaying rapidly, impart to the deposited liquid that brownish green 
hue characteristic of most pysemic abscesses. In other words, the pus of 
secondary pysemic deposits consists of the same liquid as that which circu- 
lates in the vessels, but inspissated, because the surrounding tissues rapidly 
reabsorb a large portion of the serum. The leucocyte infested with micro- 
zymes loses much of its amoeboid nature, but it is not known that it also loses 
its power of emigration. To sum up, the pus, which is deposited in various 
parts of the body, is not a secretion, nor a mechanical transfer of fluid 
formed in one part to another part of the body ; it is simply produced by 
emigration of leucocytes, more or less broken down and otherwise changed 
during a non-inflammatory stasis ; but both the leucocytes and the accom- 
panying serum are often modified by the direct influence of septic poison, 
i.e., are themselves in a state of commencing or partial putrescence. 

Hitherto I have only spoken of clinical septicaemia or pyaemia as consecu- 
tive to wounds, necrosis, and childbirth, the most common antecedents of 
the more rapid and violent forms of those manifestations. Of the existence 
of idiopathic pysemia I am extremely sceptical, because there is considerable 
difference between a disease whose source we cannot discover and one 
which has no source at all. When we take into account the immense ex- 
tent of skin and mucus, perhaps one should include serous surfaces, any 
little abrasion of which is quite capable of absorbing germ-charged fluids, 
when, also, we know that many of these surfaces are exposed to influences 
from without, we cannot but recognize great facilities for overlooking any 
small breach of surface. The intestinal tract, including all parts between 
the fauces and anus, are, especially at either extremity, very liable to cracks 
or ulcers. The vaginal and uterine membranes offer gates through which 
some form of blood-poison may only too readily pass ; and I err greatly if 
the urethra in the male do not open another door for such disease as is usu- 
ally termed idiopathic. 

Case XTV. — In the year 1868 1 was called, in consultation with Sir Thomas 
"Watson, to a gentleman about thirty years old, who, in the course of an 
acute lung malady, had become affected with swelling and pain of the right 
knee-joint. I recognized the enlargement and general condition as a very 
wall-marked case of pyaemia, and have little doubt that the lung malady, li 
not of the same origin, was one involving secondary abscess, for that organ 
opened into the pleura, giving rise first to great pneumo-thorax, then to 
empyema. Subsequently other joints became affected, and a large abscess 
appeared below the middle of the thigh. The patient died, and no post- 
mortem examination was obtainable. I had carefully examined all accessi- 
ble parts during life, and found no wound. The only perceptible source of 
infection was a miliary eruption, which had caused .him to scratch a good 
deal. It was not until several years afterward that a friend of this gentle- 
man confided to me that a little before his fatal illness he had contracted 
gonorrhoea of a virulent type — a fact which he was assiduous and success- 
ful in concealing, and at the time I saw him I could find no such discharge, 
which had doubtless ceased. 

Case XV. — L. C, aged twenty-two, came to me in November, 1877, 
suffering from prostatitis, the result of a gonorrhoea. He was in consider- 
able pain, had very frequent micturition, etc. He was getting rid of this 



ON PYJ3MIO JOINT DISEASE AND OTHEK AFFECTIONS. 71 

trouble when, having urgent business, he went to his chambers, where, ow- 
ing to some blunder of the laundress, he was for some time in a fireless 
room. Next day he had a cold, toward evening felt very unwell, had a 
slight rigor, passed an almost sleepless night, and next day sent for me. I 
found him with hot, rather dry skin, white tongue, furred at the back, and 
other signs of pyrexia — thermometer 101.4°. He complained of severe 
aching at the loins, and of wandering pains about the joints, but more es- 
pecially was the right shoulder very painful. I could find no swelling of 
this part. Of course the gravity of these symptoms was easily recognized. 
I prescribed a purge, and immediately on its action ten grains of quinine 
every six hours. Next morning he was rather better, and I ordered the 
quinine to be continued every four hours. In the course of the next after- 
noon he had two or three sharp rigors, and when I saw him two hours 
afterward, he had a temperature of 103.2°. The left knee was the joint 
chiefly affected, the left elbow was less swollen, and but slightly painful ; 
there was no pain at the right shoulder. On the fourth and fifth day after 
the third rigor much the same as on third day. On sixth day left wrist swol- 
len, with evident effusion into posterior tendinous sheaths ; temperature in 
the morning, 102.8° ; in the evening, 104.4°. 

On eighth day. — Knee very painful and large, with palpable fluctuation ; 
synovial membrane seemed dangerously distended ; punctured the joint 
with piston-trocar and hydraulic tube, drawing off nearly five ounces of pus 
mixed with glomeruli. The right sterno-clavicular joint appeared also 
swollen, but there was no pain in it. 

On tenth day. — The knee was but very slightly larger than after the 
puncture ; the swelling over the right sterno-clavicular joint had assumed 
the appearance of a superficial abscess. The temperature had declined 
somewhat ; it was 100.5° this morning, 102.3° this evening. 

On twelfth day. — Opened antiseptically the abscess over inner side of 
sternum, which had become subcutaneous — temperature to-night, 101.2°. 
The knee not painful except on movement, and but very slightly swollen. 
After this the patient gradually mended, but the evening temperature 
remained over 100° for another fortnight. At the end of that time he 
drew my attention to an abscess on the right groin above Poupart's lig- 
ament. This was opened, and about three ounces of pus escaped ; it was 
washed out with five per cent. ■ solution of carbolic acid, and dressed with 
gauze. 

After the discharge of this abscess the temperature declined to only a 
little above normal ; the wound in the groin and at the clavicle healed. The 
knee-joint had nearly regained its natural size, but its movements were a 
good deal restricted. 1 

Case XVI. a — " A patient in the Bristol Infirmary for gonorrhoea and or- 
chitis was attacked with great pain and swelling in the right knee. In a 
few days the lower part of the thigh was filled with matter which had es- 
caped from the distended synovial membrane. The limb was subsequently 
amputated and the joint found to be completely disorganized." 

.Although I have still no post-mortem examination to prove a view which 
I first enunciated in I860, 5 that the so-called gonorrhoea! rheumatism is a 
mild form of pyaemia, I think the cases just quoted are sufficient to show 



1 The restoration of mobility to this joint is alluded to in another chapter. 

2 From the System of Surgery, vol. iv. , p. 35. 

3 See first edition of this treatise, p. 79. 



72 DISEASES OP THE JOINTS. 

that gonorrhoea will occasionally produce pyeemia. We have already seen 
that blood-poisoning is not by any means uniformly intense (p. 63), that 
either a certain sluggish form of contagium wvum, dumb-bell, mierozymes 
or a condition of fluids and tissues incapable of cultivating the more active 
forms, modify the disease down to a slight, comparatively harmless pro- 
cess ; therefore the fact that gonorrhoea! arthritis does not kill the sufferer 
does not by any means disprove its pysemic origin. 1 

Indeed, as my study and experience of joint disease have gone on in- 
creasing, I have been forced to expand these views, and am able to state 
with complete conviction that other forms of synovitis— one connected with 
pregnancy independent of and previous to childbirth, one with disturb- 
ances of the menstrual function, and one with exantnematous and other 
fevers — have all a like origin ; that is to say, from absorption into the blood 
of a deleterious material, which is in some of these diseases not pus, yet 
may be retained, and partially putrescent discharge, or the unhealthy excre- 
tions -of a foetus in utero. Thus we shall have to speak of various forms of 
these similar, but not identical affections, according as they are connected 
with the different systemic maladies or conditions above notified. With 
regard, however, to that malady, which has been most usually observed as 
a complication of gonorrhoea, it will be well to remember that its connec- 
tion with that discharge is not constant, but that it has also been known 
to follow the use of catheters or bougies. 2 Hence, as its name, gonor- 
rhceal rheumatism, is, in both adjective and noun, misleading, I propose 
henceforth to term it urethral synovitis. 

As to the similar or even identical condition arising from disorders of 
female organs, it would be well also to have a distinct name, and I would 
propose metric or perimetric synovitis. 

Symptoms. — Blood-poisoning by a septic influence derived from without 
exhibits in different persons various degrees of intensity. The most rapidly 
fatal form has received the name septicaemia, a less severe form is termed 
pysemia ; but it will have been gathered from the preceding section that 
there is no generic difference between the two diseases ; the latter is proba- 
bly only distinguished clinically from the former by a rather more pro- 
tracted course, which gives time for the deposition of pus from the blood. 
The condition may be idiopathic (so called), that is to say may arise from 
no discoverable cause, such as wound, childbirth, etc., but far more fre- 
quently is in direct relation with some such condition. After a few hours 
of malaise, want of appetite, headache and perhaps wandering pains, rigors 
more or less severe are followed by a rapid rise of temperature, more rarely 
the pyrexia may supervene without any rigor. Such manifestations usually 
arise between the fourth and twelfth day after childbirth, but may occur at 
any time after receipt of a wound, for it is impossible to say when the 
poison may have been applied. When the disease arises from a visible 
wound, the skin around is, in the worst cases, of a dusky purple, roughened 

' This was the chief objection urged against this theory of causation. The possi- 
bility of a surface-pus becoming putrid and absorbed by an unbroken mucous mem- 
brane must not be ignored. 

'-' The clinical conditions of these cases lead one to suspect that one item may have 
been overlooked, namely, the possibility of some infective matter having been intro- 
duced on the instrument. I do not mean the pus of a gonorrhoea, but something in 
more or less a septic condition— be it a little putrescent mucus or blood adhering to 
the eye of the instrument, be it oil, into which many catheters and other things have 
been dipped. The urethra is often roughly treated by Holt's dilators and other things 
without producing joint-troubles, while these complications are said to follow occa- 
•ionally very gentle manipulation. 



ON PYiEMIC JOINT DISEASE AND OTHER AFFECTIONS. 73 

by little nodules, tubers or pustules ; beyond this deeply tinted part is a 
zone of less strongly marked color, varying often into brown, which gradu- 
ally fades at the circumference into the normal hue ; all this part, if it do not 
do so at once, soon pits on pressure, losing at the same time its color, which 
on removing the finger soon returns. If the surface be granulating these 
growths either suddenly disappear, put on a sloughy appearance, or may 
simply be dry, congested and lurid. The discharge changes its character 
from healthy pus to sanies, or ceases altogether. Lochia in puerperal cases 

* become altered in color, scanty or altogether suppressed. The rise of tem- 
perature is in different cases of various character. The thermometer may, 
after the first rigor, bound with a sudden, spring up to 102° — 106°, and while 

• observing a slight day-and-night fluctuation, never falls to near the normal. 
In other cases it may decline to 100°, or less, and then after another rigor 
rise again : this fluctuation I have known repeated very many times. An- 
other mode of elevation is more gradual ; the temperature may each Dight 
rise a degree, or a large fraction of a degree, higher than the night before, 
and sink in the morning nearly to the norm, so that the gradients become 
deeper and more violent for two or three days. After this, with or without 
the recurrence of a rigor, the thermometer keeps up to 104° or 104.5° 
evening, 101° or 102° morning. The skin is usually moist or rather clammy ; 
there is a peculiar sickly sweet smell, both of the perspiration and breath ; 
the tongue at first is white at the edges and tip, brown farther back and in 
the middle, then becomes thickly furred, and at last brown and dry. Breath 
is taken by suspiration rather than by respiration. Pehrium of a low form, 
though occasionally violent, is a frequent symptom. The pulse at first is 
bounding and rapid ; it soon loses the resilient quality, becoming small and 
too quick to count. The patient sinks rapidly, dying of asthenia. Certain 
symptoms, such as purging, occasionally with bloody stools, violent and 
persistent vomiting, hiccough, are frequent, but not constant. A very de- 
pressed and despondent mental condition is nearly always present. 

In the worst form, just depicted, any joint-affection is not common ; in 
the less violent malady, as when the temperature takes some days to rise, 
and rigors are recurrent with considerable regularity, when the condition 
of the wound alters but little or not at all, and when violent sweating now 
and then appears a critical symptom, pus becomes deposited in various 
parts of the body ; such deposit being preceded by capillary engorgement, 
which gives rise to special symptoms, according to the organ attacked. 
Pysemic icterus, dyspnoea, delirium, etc., are well known. Joint-affection 
manifests itself generally by severe pain and swelling. Very often in the 
less acute cases there will be for a time those flying uncertain pains which 
are so often termed rheumatic (malum rheumaticum vagum), then the dis- 
ease localizes itself in one or more, commonly in several, joints, and fre- 
quently also in synovial sheaths, sometimes exclusively in these latter. 

The local articular manifestation of blood-poisoning is very much the 
same, whatever be the particular material absorbed. I mean a severe case 
of joint disease, originating in pyaemia, will have the same local symptoms 
as an equally severe case following typhoid fever, gonorrhoea, scarlatina, 
etc. Mild cases also run in like grooves ; nevertheless there are some ex- 
ceptions in regard to certain poisonous influences, which will be noted in 
their place ; the variations, too, as to severity, period of advent, relations 
to changes in the systemic affection, etc., produce a series of commutations 
in the clinical aspects of the disease, which I can scarcely hope to repro- 
duce, and quite despair to exhaust. I can at .all events attempt to give a 
general outline of this whole class of joint-affections. 



74 DISEASES OP THE JOINTS. 

The disease is nearly always multiple ; the articulations most prone to 
poison influence are, in the following order, these : knee, elbow, wrist, 
ankle, shoulder, sterno-clavicular, hip ; ' but the smallest joints, as the 
temporo-maxillary, carpal, tarsal, and phalangeal, may participate in the 
disease. 

"When joint-affection has lasted from five to ten days in a multiple form, 
the malady usually recedes, if the systemic symptoms improve from all 
articulation except one, or at most two of those first on the list. The pain 
is slight while the part is at rest ; and herein is a marked difference between 
this class of disease and rheumatism or gout ; but the slightest movement 
produces intense suffering. Especially is that sort of pain we call tender- 
ness a prominent symptom ; it is not merely deep but superficial also — 
indeed, in some cases, the patient winces and whimpers at a rather slight 
touch, or at first contact, and shows less sign of pain on deeper and con- 
tinued pressure. 

As a rule, the swelling in all this order of disease is white. If redness 
be present at all, it will be of dusky quality, and in lines, racemose and in 
the axis of the limb, while the skin between them is markedly white. The 
swelling does not, as a rule, fluctuate evidently and plainly, like a suppura- 
tive or serous synovitis, although in certain cases of any form of virus- 
induced synovitis, the joint becomes largely distended. CEdema, more or 
less marked, occasionally coincides with the swelling, and then exceeds its 
limits ; often indeed, especially if the disease be at the ankle or the 
knee, the parts below are very markedly ©edematous and much swollen ; in 
such cases large cutaneous veins meander over the tumid joint. If this 
oedema encroach upward, and be well developed for some distance above 
the articulation, suppuration, if the patient recover, will probably destroy 
the joint. The shape of the swelling, except in the rarer cases of intra- 
articular distention above alluded to, does not follow the shape of the 
synovial membrane, but is formless and round ; sometimes distention of 
tendon-sheaths is evident to the eye, more often to the hand. There is very 
considerable tendency to metastasis from joint to joint in the earlier stages 
of the affection — early, that is, both of the general and local disease ; many 
joints may be affected one after the other, and any one of them, either the 
first or the last attacked, or any intermediate one, may alone be the seat of 
any permanent or long-standing malady. Metastasis from a joint which 
has been seven days swollen is uncommon, although it may slowly recover. 
The knee, whatever other joints may have suffered, is most usually the seat 
of lingering disease. 

Local heat cannot be verified ; either there is no difference between the 
general and local temperature, or the latter is masked. 

Urethral synovitis is generally the result of a gonorrhoea, not in the acute 
stage ; but of a long-standing, obstinate, or neglected attack. It is an error 
which has been pretty nearly exploded, to imagine that joint-complications 
are produced by the rapid suppression of a gonorrhoea, for it is in long- 
standing cases that such troubles arise. It may also follow the use of car 
theters, etc. The malady usually commences with a rigor, always does so, in- 
deed, when it results from catheterization ; then comes pyrexia, with a tem- 
perature of 100° — 102°, very rarely more ; this is accompanied, or quickly 
succeeded, by rather severe pain in one or both knees, and generally in 
some other joint or joints. The knee very rarely escapes, I should have 
said never, but for a single case that came under my care. Not unconv 



1 In typhoid synovitis the hip changes its place, coming first, even before the knee. 



ON PYEMIC JOINT DISEASE AND OTHEK AFFECTIONS. 75 

monly another complication is combined with the joint-affection, namely, 
conjunctivitis (not the violent inflammation from direct infection), more 
rarely iritis. The joints affected are white, and although in the commence- 
ment, and at the knee there is evident intra-articular effusion, this is less 
marked in other joints, and soon subsides, the chief enlargement being 
certainly peri-articular. The acute phase is not of long duration, but is 
succeeded by a subacute stage, during which the patient's health is greatly 
depressed ; pain while at rest being slight, on movement pretty sharp ; ten- 
derness is very strongly marked. This phase is exceedingly obstinate, and, 
even when the patient has appeared well while in bed, he no sooner gets 
about than all the symptoms may return ; this state of fluctuating recovery 
and relapse may continue for months. Even after what appears entire re- 
covery, an exposure to cold or an error in diet, especially in drink, will 
bring on a recurrence. If the individual have been so unfortunate as to 
contract a fresh gonorrhoea he will hardly escape another attack of synovi- 
tis. I have known such recurrence occur after an interval of nine years, 
during which the patient had been married, had children born to him, been 
left a widpwer, and even what seemed most likely to change the habit of 
body, had spent nearly four years in the tropics. Singularly enough, too, 
it is by no means a necessity, though it may so occur, that the same joints 
which suffered in the old should be affected in the new attack. ' • 

Metric Synovitis. — With the greatest desire to avoid unnecessary or pe- 
dantic refinements I must yet point out that there are in the cases of mul- 
tiple synovitis arising in women and analogous in their symptoms and pa- 
thology with the urethral synovitis of males, certain clinical distinctions 
dividing them into three suborders, one occurring during pregnancy, one a 
month or six weeks after parturition, the third in non-pregnant women, 
virgin or otherwise, and connected with menstrual irregularity, generally 
with sudden suppression of the catamenial discharge. They all owe their 
origin to the absorption into the blood of deleterious materials. 

The ante-partum synovitis of puerperal women begins between the 
fourth and seventh month of pregnancy, the post-partum from a month to- 
six weeks after childbirth ; occasionally there seems a continuity, inter- 
rupted by parturition, between the two attacks. The earlier one, with 
which we are now specially concerned, is most common (judging from the 
cases that I have seen) in women, who, previous to pregnancy, have suffered 
from considerable leucorrhcea, which on fecundation has been suppressed, 
or nearly so. The commencement of the disease is like the usual pro- 
droma of a feverish attack. Eigors may be sometimes absent, but pyrexia 
is always present, with great malaise depression, and those vague pains in the 
back and limbs, which seem, even to the patient, like rheumatism. Soon 
these pains fix themselves in the joints, and for the first few days in several 
joints, leaving some and attacking others capriciously. Generally after or 
about the sixth day, the fever declines, the disease withdraws from all other 
articulations and attaches itself to one knee or hip — sometimes, but more 
rarely, two joints are affected ; the above named, of opposite sides, seem to 
be more often companions in this attack than any other, but the knee and 
shoulder have simultaneously fallen under my care. If the disease become, 
after its first excursive character has passed away, mon-articular, the knee 



1 Volkmann says, " I have treated two persons, who during a long series of years 
suffered, one seven times, the other four times, from gonorrhoea, each time compli- 
cated with poly -articular joint-inflammations which confined them to bed for months." 
— Pitha's and Billroth's Handbuch der Chirurgie, Bd. ii., p. 505. 



76 DISEASES OF THE JOINTS. 

is, I think, more often than any other the chosen joint, 1 but the hip alone 
is also a favorite place of attack. The joints affected are very painful on 
movement ; only slightly so if at rest, but are very tender, even to light 
contact. The enlargement is not considerable, especially in joints which 
are soon deserted, but in those which have been affected from three to six 
days, the swelling is pretty severe. It is quite as much peri- as intra-articu- 
lar ; hence fluctuation, though it may be detected, does not so much fix at- 
tention as the doughy, shapeless,' slightly pitting tumefaction I have so 
often described. 

Women with this disease sometimes abort, or are prematurely confined ; 
then the joint gets well slowly, use of the articulation being difficult to re- 
establish, not so much from stiffness as from weakness and looseness of 
parts, or if the disease have advanced further before abortion comes on, the 
joint will be anchylosed, even abscess may form, and a protracted suppura- 
tion, ending in destruction of the joint, will result. The worst form of case 
is a very serious, usually a fatal, disease. Such termination is to be dreaded, 
if after from four to six days the pyrexia, with which, as we have seen, the 
disease commences, do not decline, or if it do so, returns again with even 
higher temperature after one or two irregular rigors. In such a case the 
tongue becomes furred and brown, sweating is profuse, restlessness ex- 
treme, and pain in the affected joints severe ; they too are more markedly 
swollen, fluctuate, are evidently suppurating. Abortion about the third day 
after the renewed pyrexia ushers in the last act of the tragedy. 

In the mildest form of the disease, the temperature having declined, the 
joint, properly splinted and protected, remains swollen, getting sometimes 
a little better, but remaining tender until about ten days or a fortnight be- 
fore the normal period of parturition, when the symptoms almost sudden- 
ly disappear ; and if childbirth, and the after-effects be successfully passed 
through, may never return. 2 If the mother have a good supply of milk and 
suckle the child, she will probably escape a post-partum repetition of the 
disease. If she have little milk, or more surely, if a plentiful lactation be 
for any reason suppressed, the disease is almost certain to come back. I 
shordd say that in all these cases unusually careful irrigation with carbolic 
acid of the genital passages would be advisable after the birth of the child 
(p. 81). 

A similar form of disease commencing between the second and fifth week 
after childbirth is rare, unless it have been preceded by the malady just 
described. 3 I have seen only four cases in an extensive and careful experi- 
ence of more than thirty years, yet have some reason to believe that many 
more would be observed were they not as a rule ascribed to rheumatism, 
for the malady begins with pyrexia and vague pains followed by a multiple 
joint-affection, which has great proclivity to the shoulders, elbows, and 
wrist ; yet after a time usually passes to the joints of the lower extremity. 
The commencement is by one or two indistinct rigors, then wandering pains 
in the shoulders and other joints of the upper limb, which swell somewhat, 
-the enlargement being chiefly or entirely thecal. While at rest, the pain 



' A mere local result of pregnancy, described by Gmelin, Joyeux, and others, viz., 
■softening and loosening of the pelvic symphyses is not to be confounded with this dis- 
ease. 

3 Here we see are two forms alike in all points but this: in the former the fever 
■declines and the woman retains the foetus until the temperature is normal — she gets 
well. In the latter the pyrexia is continued, and abortion begins at a temperature of 
102° or more. The infant may in either case be born living, but is more often d <1 

3 Of course I am not here speaking of puerperal pyaemia. 



ON PYEMIC JOINT DISEASE AND OTHER AFFECTIONS. 77 

is merely a dull aching, but on movement is very sharp. It may be that 
the cause of this first predilection for the arm is the exertion of holding or 
lifting the baby. The pyrexia is not great, reaching rarely to 102°, and 
most commonly fluctuates between 99° and 101°. In only one of the cases 
that came under my notice did any permanent evil remain ; this was a false 
anchylosis of the elbow-joint. The absorption or suppression of parturition- 
discharges appears to be the efficient cause of this disease, whose course 
resembles 

Calamenial synovitis, a name whereby I designate joint-inflammations 
Connected with certain accidental menstrual irregularities or interruptions 
produced by some external cause, such as fright, exposture to cold, etc. I 
have seen so many cases of this description that I can with certainty affirm 
the interrelation of cause and effect between the two phenomena. (See Cases 
XXV. and XXVI.) The peculiar synovitis generally attacks women of deli- 
cate constitution 'and lax fibre, subject to leucorrhcea, who have borne chil- 
dren, and above all have suffered from miscarriages, generally recent ones. 
If such persons having been exposed to cold, or having got wet during men- 
struation, especially at the commencement of that function, have the flow 
stopped suddenly, they are very likely to develop some form of inflammatory 
disease, erythema, erysipelas, or affections of internal organs, diarrhoea with 
' gastric catarrh, etc. A certain number, instead of or with these maladies, 
develop a synovitis which is often sharp and severe. The disease is at first 
multiple, commencing with a smart attack of pyrexia, generally preceded 
by rigors ; wandering pains, often ascribed to rheumatism, affect the joints, 
also the loins and hips ; then these sensations localize themselves in one or 
two joints, and probably terminate by affecting one only, and that one 
nearly always the knee. The symptoms correspond very much with the 
general sketch above given of this kind of joint-disease, the swelling being, 
as a very general rule, chiefly peri-articular : in a few cases, however, intra- 
articular swelling is unusually strongly marked. Such are the cases which 
terminate in abscess of the joint ; the more common tendency of the dis- 
ease is toward false anchylosis. 

Synovitis during typhoid fever is a sufficiently rare affection ; yet in 
certain epidemics has been less -uncommon than in others, a circumstance 
which we have no means of explaining. Thus Stromeyer ' saw in a severe 
visitation at Munich three cases, while Guterbock * says that, in the four 
years, 1868-71 inclusive, the k.k. Krankenhaus at Vienna treated 3,130 
cases of typhoid, among which only two joini^complications occurred. I 
have been permitted, through the kindness of my friend Dr. Broadbent, to 
test the records of the London Fever Hospital. It appears that in that in- 
stitution no such complications have been recorded. But I can adduce a 
goodly array of such cases ; for instance, Mr. Bellamy excised, in January, 
1880, the hip of a boy aged eleven, who had suppuration of that joint oc- 
curring in the course of typhoid, and I shall shortly refer to some cases 
with which I was personally concerned. I have been fortunate in seeing, 
what must be considered, in so rare a malady, a large number of cases, 
and conclude from this experience that it includes two forms. The one 
which is confined, or almost confined, to the hip, commences at the end of 
'the second or beginning of the third week — it is intra-articular, and pro- 
duces rapid effusion and dislocation. This form is usually so painless, or 
the fever causes such an apathetic condition, that the patient is unaware of 



1 Stromeyer's Handbuch der Chirurgie. 
'Langenbeck's Arohiv, vol. xvi. , p. 62. 



78 DISEASES OE THE JOINTS. 

any trouble at the part, and the disease is not infrequently recognized only 
when the patient is convalescent, and about to quit the bed, when luxation 
becomes evident. It is very rare that attempts at replacement succeed ; 
but the limb very rapidly regains a considerable power of restricted move- 
ment. 

The other form is multiple, begins toward the end of the second 
week, and occasions more suffering. Tenderness and pain on movement 
are especially strongly developed. The swelling is marked by considerable 
cutaneous redness, and puffiness, peri-articular abscess threatens constantly, 
yet may disappear, oedema of parts beneath the inflamed joint is common 
and strongly accentuated. The disease is always lingering. Albumen, 
generally a mere trace, sometimes in larger quantity, is commonly present 
in the urine. 

This form is to be considered pysemic, and resulting from the intestinal 
ulcerations, 1 giving rise to absorption into the blood of a materies morbi 
It is very probable, though there is no proof of such fact, that one of the 
many forms of cocco-bacterium is in such cases the peccant matter. The 
disease, as affecting the synovial and peri-articular tissues simply, must be 
carefully distinguished from a form of osteomyelitis, which is also an occa- 
sional sequela of enteric fever, which attacks the limb-bones, and which, if 
it occur near a joint, will, of course, give rise to articular inflammation. 

Exanthematous synovitis is not infrequent as a sequela of scarlatina, 
diphtheria, small-pox, measles, and even may follow chicken-pox. Mumps, 
as is well known, is much subject to metastasis ; to the brain, to the tes- 
ticle, and also, though less often, to the joints. It is said also that dysen- 
tery, at the time when recovery begins, is also thus accompanied ; but 
scarlatina and measles are most prone to joint-complications. These affec- 
tions have often, like gonorrhoea! joint-maladies, been ascribed to rheuma- 
tism, even have been termed "consecutive rheumatism." But the only 
point in their course and condition which at all resembles the rheumatic, 
is that they are nearly always multiple ; they possess neither the tempera- 
ture of rheumatism, nor the slightest tendency to involve either the mem- 
branes of the heart or brain." As a very general rule, the joints become 
affected singly, though rapidly, after one another, a knee, or perhaps both 
knees taking the precedence. The pain is in some of the cases rather severe, 
the temperature usually between 101° and 102°, more often at the lower 
than at the higher figure ; the swelling is not considerable, and involves the 
peri-articular tissues more frequently than the synovial cavity itself, since 
through the reddened, perhaps even slightly cedematous, superficial tex- 
tures no fluctuation, as in sero-§ynovitis, is perceptible ; also it is to be ob- 
served that the superficial veins are not enlarged and strongly marked, as 
is always the case when oedema accompanies the more deeply seated in- 
flammation. 

This synovitis is generally a mild affection, coming on about the time 
when the skin or throat affection is declining, and usually gets well three 
or four days after the exanthem may be taken to have disappeared ; in 
such cases the effusion is probably merely the puro-synovia already de- 
scribed (p. 26). In rarer cases the joint disease lasts longer, and this 
nearly always only at' the knee, other articulations getting well. Such a' 



1 The first described mon- articular synovitis, confined almost entirely to the hip, 
can hardly be otherwise than a specific part of enteric fever. 

1 A metastasis of mumps to the cerebral meninges occasionally occurs without joint- 
affection. 



ON PYEMIC JOINT DISEASE AND OTHER AFFECTIONS. 79 

joint goes through phases somewhat different to those of catamenial syno- 
vitis. These cases, too, vary somewhat among themselves, according to 
the age of the person attacked, and also according to the nature of the 
exanthem. The joint-affection following scarlatina tends "more often to 
the suppurative form, and to produce, if the attack be at all severe, either 
disorganization or anchylosis very rapidly. 1 The synovitis which follows 
measles is, more than any other of these secondary inflammations, in- 
clined to fall into a chronic phase after a subacute attack of a few days, 
and then to give rise to, or to become changed into, strumous synovitis. 
(See Chapter V.) This tendency of strumous inflammations to follow 
measles is not confined to joints, but may also be observed with regard 
to cervical lymphatic glands, palpebral conjunctiva, auditory meatus, 
etc. Thus if the histories of strumous inflammations be elicited with care 
and minuteness, one always finds a considerable proportion commencing 
after convalescence from measles. The scrofulous diathesis was, of course, 
present previous to the attack, and though we cannot trace what direct 
link there may be between measles and a more' marked development of 
strumous cachexia, one cannot but observe that many scrofulous children 
are said to have been quite strong and well, previous to an attack of 
measles ; and that of those who suffer from struma after that exanthem, 
many have chronic joint disease. 

The slighter forms of exanthematous joint diseases run a mild and rapid 
course ; the whole trouble having generally ended, leaving no reliquiae in 
about a fortnight, and since the joint-affection arises toward the end of the 
exanthem, the recoveries from both maladies succeed each . other thus : 
from the eruptive fever, three or four days before j;he joint-affections recede ; 
that is to say, the foci of infection being dried up, the infection ceases. 
The gravity of the poisoning is in proportion to the quantity of the poison. 
But sometimes an exanthematous synovitis is evidently pyasmic, and patients 
even die of such disease, consecutive to one of the skin-fevers ; and then 
the joint-affection, considered merely as a symptom, is barely mentioned. 
Such mortality only occurs when the pristine malady leaves behind it some 
suppurating focus, such as a pharyngeal ulcer from scarlatina, measles, or 
diphtheria, one or two obstinate sores after small-pox, a suppuration of the 
parotid after mumps, a meso-rectal or meso-colic abscess after dysentery, 
etc. Here the origin of infection continuing, the infection itself goes on. 

Another, a mon-articular form, is likewise said to occur as a sequel to 
exanthemata or to dysentery. This, however, must be extremely rare for 
all such diseases. I have never seen a case of exanthematous synovitis 
commencing in a single joint. 

Treatment. — The treatment of pyaemia hardly falls within the scope of 
a work on joint disease ; nevertheless, without some directions as to such 
management, this chapter would be so sadly incomplete, that it is impossi- 
ble to refrain from saying something on the subject, and the less so because 
it appears to me that what I have to say will be of some service, and may 
be the means of saving here and there a life. 

Pyaemia, even in its more severe forms, is not a malady so necessarily 
fatal that the person should be left to fate, or treated perfunctorily and 
hopelessly. On the contrary, when a patient, with a wound of any descrip- 

1 While these sheets are going through the press I have been called to a sea-side 
town to see a young lady who some years ago had, during scarlatina, her right knee 
affected. The joint suppurated, some bone exfoliated, the result being true anchylo- 
sis in an awkward position. 



80 DISEASES OP THE JOINTS. 

tion, but a fortiori with one of a sort which we know might prove infective, 
has anysymptom, such as a sudden rise of temperature, not otherwise to 
be accounted for ; more especially if the pyrexia have been preceded by a 
rigor or rigors, he should be instantly subjected to sharp and energetic 
treatment. The question of purgative must depend upon the condition of 
bowels. To purge for the mere sake of purging is not wise, since we do 
not want to promote absorption, but a clearance of loaded bowels is neces- 
sary. If mere aperient be necessary, a rather large enema, with a little tur- 
pentine in it, will save time ; if the liver appear torpid, colocynth and 
calomel may be given. The great object, however, is to administer a large 
dose of quinine as soon after the rigor as possible: I know with what 
scepticism the idea of quinine warding off pyaemia will by some be re- 
garded ; also, I cannot but be aware that if such cases of sudden rigors and 
pyrexia consecutive to wound or compound fracture thus treated, do not 
eventuate in pyaemia, it maybe said the patient would not have suffered 
much disease even without the quinine. But the sort of evidence is cumu- 
lative, and although septic disease is, I am happy to say, a great rarity in 
my hospital ; yet I have had such experience as to be able to say that in 
four cases marked by the symptoms above described, the disease was not 
developed. In a case of necrosis after fracture, the patient did have pyaemia, 
recovered after joint-affection ; in ten weeks had more rigors and pyrexia, 
when fresh treatment saved him from a second attack of the disease. 1 Lo- 
cal treatment should also be instantly employed for the purpose of disin- 
-fecting the wound and its neighborhood. Some of the experiments of 
Koch, Burdon-Sanderson, and others, show that the toxic effects of septics 
depend on a certain dose, and it would be against reason to suppose that 
this dose is taken into the system at one gulp as it were ; indeed, the clini- 
cal study of characteristic cases shows clearly that a certain malaise precedes 
the rigor, because the quantity requisite to produce this effect is not as yet 
taken up into the system, and that afterward elimination to a certain ex- 
tent goes on ; but absorption also continues, hence the recurrent rigors, the 
irregular fits of pyrexia and the general variability of the condition. Indeed 
it is evident that the system has great power of excreting the pyaemic venom ; 
hence septic intoxication, i.e., subjection of the vital powers by a single 
overwhelming dose of the poison is rare ; the usual course is by repeated 
acts of absorption with rigors, followed by pyrexia, which is interrupted by 
remissions, the result of elimination. Hence it may be doubted whether 
any case of pyaemia sufficiently recent to possess vitality fairly unimpaired 
would prove fatal, could we at once cut off all supply of fresh infective 
matter from the wound or other source of supply, and aid the system to rid 
itself of that already absorbed. 

Hence, as soon as blood-poisoning manifests itself, the wound, if large 
enough to be so dealt with, should be opened up, filled, and mopped out 
with a solution (three or five per cent.) of carbolic acid. Even amputation, 
or other operation-wounds, however deep, should be thus dealt with. If 
the source of disease be a mere puncture, a probe should be passed along 
its track, and the opening enlarged until it can be thoroughly exposed to 
the action of the antiseptic lotion. Even further measures may be taken, 

J Dr. Sidney Einger (Handbook of Therapeutics, p. 560, seventh ed.) doubts the 
value of quina in pyaamia. being, he says, "convinced that the falls in temperature 
were often normal." Perhaps this may have sometimes been the case, but I bavu 
watched the action of this drug on septic diseases too anxiously and carefully t» bavo 
been deceived in the way indicated. 



ON PYJEMIC JOINT DISEASE AND OTHER AFFECTIONS. 81 

for if the wound be charged with bacteria, the neighborhood also will be 
more or less impregnated with them. Hence parenchymatous infiltration 
with the same acid may be advantageously employed. This is best effected 
by means of a tubular needle about two and a half or three inches long, 
perforated at the sides as well as at the end, and provided with a brass, or 
silver collar, to which one end of an india-rubber tube can be attached. A 
glass tube, about two feet long, and three-eighths of an inch diameter, 
drawn at one end to a blunt point, is filled, either by suction or simple 
immersion, with a three or four per cent, solution of carbolic acid, the india- 
rubber tube — which already has one end attached to the needle — is drawn 
over the conical end of the glass, and then the needle is passed deeply 
among the tissues in the immediate neighborhood, and above the infecting 
wound. Of course, during all this time, the operator will have kept his 
finger on the other end of the glass tube ; and this he now uncovers. The 
fluid soon begins to percolate the tissues more slowly, and therefore more 
widely and evenly than when a syringe is used, and the amount is very accu- 
rately measured by the gradual descent of the liquid in the tube. This 
descent may stop, and infiltration cease, while still insufficiently accom- 
plished. Slight shifting or turning round of the needle will frequently 
renew the flow ; but, if this fail, one may apply the mouth to the end of 
the tube, and by blowing force a little more into the tissues ; afterward 
the flow generally continues of itself, or one may continue the insufflation. 
An ounce of a three per cent, solution may be injected without fear of pro- 
ducing carbolic acid poisoning and may be repeated daily, or if the pyaemia 
be strongly marked twice a day ; but during the process some of the urine 
should be preserved in an uncovered vessel ; when the secretion turns, after 
three or four hours' exposure to the air, of a blackish color, as though a few 
drops of ink were mixed with it, one must stop the procedure ; it is the 
first sign of carbolic poisoning. If this precaution be taken one need not 
fear evil results. 

If the disease be post-partum pyaemia, the genital passages should be 
thoroughly and frequently washed out with carbolic acid. Mere syringing 
is of little use, or may be worse than useless — delusive. Irrigation with 
large quantities of a four per cent, solution is easily carried out by provid- 
ing a metal bucket, at the bottom of which a tube projects ; to this an 
india-rubber pipe, terminating in a large vaginal canula, perforated at the 
end as well as at the sides, and provided with a stopcock, is attached. The 
bucket is hung high above the bed ; the patient lies on an india-rubber 
sheet, in whose folds an off-drain into a vessel on the floor can be arranged. 
The canula should be passed to the os uteri, and the stream allowed to flow 
for some time after that which comes away is perfectly clear and inoffen- 
sive ; then the instrument, the stream still flowing, should be so slowly 
withdrawn that no spot of the mucous membrane can escape. 

After three, or at most four, large doses of quinine, whatever be the 
source of poisoning, have reduced, or failed to reduce ' the temperature, the 
sulpho-carbolate of sodium should be given. A healthy person taking this 
combination, first introduced for other purposes by my friend Dr. Sansom, 
passes sulphides by the urine, while the breath is strongly impregnated 
with the odor of phenol ; hence it is evident that the blood takes up and 

1 1 have very rarely indeed found quinine fail to bring down that sudden tempera- 
ture which immediately follows a rig-or, although the thermometer may, during admin- 
istration, rise again ; but unless another rigor supervene, slowly and gradatim. 

6 



82 DISEASES OF THE JOINTS. 

holds that substance in solution, and, in so far, the liquor sanguinis must 
be inimical to bacterial life.' 

An occasional recurrence of rigors must not scare us from this treatment. 
(See Case X"VUUL.) It must be remembered that if any thrombi more or 
less charged with microzymes or putrescent be in the veins of the infection- 
focus, these matters must ultimately pass into the circulation, and that every 
fresh dose thus taken up, unless very small, manifests itself by one or more 
rigors, and a rise of temperature: If this elevation be transitory, and the 
mercury fall in from six to eight hours, the poison has been eliminated, or 
has been destroyed by the carbolic acid in the blood. We may, if the tem- 
perature be considerable after the rigor, exhibit two large doses of quinine, 
at an hour or two hours' interval, and then return to the sulpho-carbolate.' 
Shorter phases of pyrexia, longer intervals of moderate temperature, mark 
progress in the right direction. Even some frequency of rigors, if only the 
thermometer elevation be of short duration indicates rapid absorption from 
the veins, not fresh poisoning by the wound itself or the effect of poison 
already absorbed. But since the presence of bacterial poison is eminently 
depressant on the vital powers we must keep them up by food and stimu- 
lants ; frequently large doses of the latter are absolutely necessary, because 
assimilation is at a very low ebb. 

The treatment of the joint-affection is in true pyaemia of secondary im- 
portance, nor during the brunt of the disease can we as a rule employ 
splints or other retentive apparatus, for the patient in that phase either lies 
perfectly still or is exceedingly restless. The swollen joints should be kept 
"warm by wrapping them in wadding, if jactitation — and this sometimes 
■occurs — come on, a light leather or poroplastic splint may be applied to the 
npper limb or ankle, while if the knee be affected the lower limb should be 
swung. If pus approach the surface, incisions may be made (antiseptieally), 
but this is more often necessary in affections of the sheaths than of the 
joints themselves. 

As a rule, if the patient recover the joints regain mobility, entirely if 
the swelling have been slight, with some stiffness if the enlargement have 
been considerable. A good deal of this stiffness depends on extra-articular 
causes, and may be overcome when the patient's health is sufficiently re- 
stored. (See Chapter XIX.) If the distention have been such as to necessi- 
tate free incision, false anchylosis usually results, though a case here and 
there may recover with very excellent mobility. 

The treatment, both general and local, of puerperal pyaemia should be 
on the same lines. As consultant concerning the joint-affections I have seen 
a good many such cases, and have of late years earnestly pressed free irri- 
gation of the genital passages with carbolic acid solution. A few cases saved 
(one is related in the sequel) are I believe almost entirely attributable to 
this practice. The irrigation should be carried out by means of a bucket 
hung sufficiently high to give through the india-rubber tube a stream of 
some power. Medical treatment and support must, of course, be employed, 
as in traumatic pyaemia. 

Urethral synovitis is much more manageable if it arise from catheterism 
than if it originate in gonorrhoea. Such cases are rare ; the discharge 

1 It would at first sight appear that salicine. or its derivatives would have a like 
effect, since its passage through the kidneys demonstrates its solution in the blood. 
Thus guided I have tried the drug, but have found it quite without any power in the 
expected direction, and this in persons in whom the sulpho-carbolate medication was 
evidently beneficial. 



ON PYEMIC .TOINT DISEASE AND OTHER AFFECTIONS. S3 

which accompanies the attack, slight though it be, suggesting the possible 
action of infective influences (p. 74), would cause us to think of some dis- 
infecting injection. The sulpho-carbolate of sodium or thymol might be 
used for this purpose without fear of irritating the urethra. "Whenever 
rigors, as is not infrequent, occur after catheterism, the surgeon must bear 
in mind the possibility of joint-complications, the treatment of the former 
is the prophylactic (not perhaps always successful) of the latter, viz., either 
a massive dose or two of quinine, or what seems to answer equally well, a 
glass of very hot whiskey or brandy-and-water, and keeping the patient for 
three or four hours sweating under a thick pile of blankets, the sulpho- 
carbolate of sodium might then be prescribed. If in spite of this treatment 
joint-complications arise, they must be treated in the same way as gonor- 
rhceal synovitis, but the case will be more manageable. An error now 
nearly discredited, whereby the joint-affections of gonorrhoea were attribu- 
ted to rapid suppression of discharge, led to attempts at bringing back ure- 
thral suppuration — this, at all events, should never be done ; on the con- 
trary, the correct practice is to check what discharge may still remain. I 
need not here describe the treatment of obstinate gonorrhoea, but would 
nevertheless point to the advisability of using an aseptic injection, such as 
has just been mentioned. The joints must be placed at rest, and warmth, or 
even heat, will be found more valuable than cold. If the case be seen early, 
and be. treated after the manner of pysemia, with quinine and the sulpho- 
carbolate (p. '81), the attack may be cut short ; if it be seen later, the 
treatment be directed against a supposed rheumatism, or if the malady, be- 
ing temporized with, fall into a chronic state, the joint-affections are ex- 
ceedingly obstinate ; they certainly will not yield till some weeks after the 
last remnant of urethritis has disappeared. Under such circumstances I 
have found large doses of the perchloride of iron, several times daily, and the 
cubebs pepper, night and morning, the best remedy. If these fail, entire 
change, especially residence for a time at a ferruginous spring, usually suc- 
ceeds. 

The joints recover their mobility very slowly, and it is often difficult to 
estimate when passive movement may begin ; this is to be judged by ex- 
amining the points of tenderness (p. 31). Eubbing and shampooing may 
often be employed for some time before any motion is bearable. Frequent 
flying blisters, which during the acute phase of the attack are inadmissible, 
generally render considerable service in the lingering chronic stage, but 
vesication must be carefully avoided. 

The different forms of metric synovitis are to be treated on a similar 
plan, nor do I think anything could be gained by going over the same 
ground with slight variations. The tendency of women suffering from ante- 
partum synovitis to abort must be considered, and means taken to avert this 
occurrence ; or in some cases, if the general symptoms of blood-poisoning 
be strongly marked but without high pyrexia, abortion may be the only 
means of saving life, as permitting irrigation to reach the absorbent surface, 
and the passage outward of the peccant matter. Also I ought to point out 
that catamenial synovitis, occurring as it does in persons of irritable or ner- 
vous habit, is a very painful form of disease, which will require some little 
use of morphia. 

The greater number of exanthematous synovial attacks are mild ; rest 
and heat, with subsequent passive motion, will generally be all-sufficient to 
cure them. But the joint diseases which result from typhoid and scarlet 
fever are more severe. Both these affections being concomitants of dan- 
gerous degrees of fever, are often overlooked, or if observed, cannot be 



84 DISEASES OF THE JOINTS. 

treated in the then condition of the patient. Hence the malady is generally 
first discovered when it is too late, or nearly too late to save the joint. The 
articular affections which follow, or are concomitant with dysentery, are 
simply pyaemia, generally of rather a mild type so far as danger to fife is 
concerned, but occasionally leading to destruction of the affected joint. 

In conclusion, I must point to the following cases for proof of the above 
facts and views which are new to surgical science. Many more cases than 
are here detailed might have been quoted, could more space be assigned to 
this most interesting subject. 

Case XVI — Jane S. died of pyaemia in Charing Cross Hospital May 3, 
1879. She came, under the care of Dr. Silver, with an abdominal tumor, 
February 17, 1879. The exact nature of the case was at first obscure, the 
general symptoms and temperature somewhat resembling enteric fever. 
The tumor was soon made out to be an abscess, probably, however, of the 
abdominal wall only. On March 20th this was opened ; it remained open 
and discharging for four weeks, and then closed. The discharge had no 
sooner ceased than pyaemic symptoms manifested themselves. The chief 
complaint of pain was in the left shoulder and a spot beneath the clavicle, 
just inside the coracoid process. Her death was from asthenia. 

Post-mortem. — The abscess was, as diagnosed, external to the perito- 
neum but close to that membrane, an adhesion had taken place between 
its inner surface and the omentum, another with the liver ; but beyond this 
there were no signs of peritonitis. The muscles surrounding what had been 
an abscess were of a slaty green hue. One of the portal branches and the 
ramifications immediately next to it in the substance of the fiver were filled 
with thick pus. This seemed corked down in the larger vein and in most 
of the twigs by coagulated but otherwise unaltered blood. The spleen was 
large, otherwise healthy, as were other abdominal organs. The thoracic 
viscera healthy, save that the pericardium contained a large quantity of fluid. 

The brain was very pale, its upper surface appeared through the arach- 
noid of a dead or yellowish white. The vessels of the pia mater contained 
here and there inspissated red blood ; in other parts a thin yellowish fluid, 
which, on pressure, flowed backward and forward in the venous twig, and 
had all the appearances of thin pus. In the suter the subarachnoid fluid 
was cloudy and turbid ; when on puncturing the membrane this liquid es- 
caped, it was found to be somewhat gelatiniform, and its turbidity was due 
(examined microscopically) to an admixture of leucocytes or pus-cells, many 
of which were broken and of irregular outline. The ventricles also con- 
tained a like fluid. The brain substance, even the gray matter, was very 
white. No puncta of divided vessels were seen. No abscess was found in 
any viscus ; no pus in the vena cava, portal, splenic vein, nor in the cere- 
bral vessels. 

Pus was found around the left shoulder-joint, immediately beneath a 
greatly thinned deltoid. This peri-articular pus communicated through two 
capsular openings with the shoulder-joint, one of which was on the outer 
side near the bicipital groove, the tendon from which had disappeared. 
The joint being opened, the synovial membrane was found of a very light 
pink, and so slightly roughened that this condition could only be seen when 
the membrane was held up so as to reflect the light. On the inner and 
posterior aspect of the capsule was another opening, which could be traced 
back to a large abscess-cavity, between the subscapular muscle and the ven- 
ter of that bone. 

The cartilage on the humerus had become exceedingly thin throughout* 



ON PYEMIC JOINT DISEASE AND OTHER AFFECTIONS. 85 

but in only one part, about one inch long by one-third of an inch broad, 
had it quite disappeared. Over most of the surface it had become so thin 
that the bone looked at first sight bare, but a little examination showed 
that a film of cartilage was still attached. This extremely thinned part did 
not end abruptly in a thicker, but sloped gradually into a thicker spot — at 
the upper aspect of the globe. The cartilage remained quite smooth on the 
surface, was not fibrillated, nor had any punctured holes in it. It seemed, 
except that it was so extremely thin to the naked eye, normal ; but under 
the microscope commencing granular degeneration, both of the cells and 
hyaline material, was evident. 

Case XVII. — Maria G., aged eighteen, had compound fracture of the 
left clavicle thirteen days before admission. On November 2d she was 
admitted under Mr. Canton's care. The ends of the bone were protruding 
and necrosed ; three days after admission she showed symptoms of pyaemia, 
of which she died November 30, 1876. 

Autopsy, December 1st. — The right ankle had been painful and swollen 
for ten days ; right wrist painful twenty-six hours ; on left metacarpus was 
a circumscribed and fluctuating swelling. During the last sixty hours of 
life intellect had been very clouded, and it was difficult to make out any 
clearly painful spots, as she cried out wherever she was touched. 

Left metacarpus. — The swelling was entirely superficial and contained 
only serum, slightly blood-stained, no micrococci. 

Eight wrist. — The veins were all full of blood, for the most part liquid ; 
in one was a clot evidently post-mortem, and not broken down. The skin 
and subcutaneous tissue, on being cut, bled almost like that of a living 
person. The areolar tissue contained a little more fluid than usual. The 
sheaths of the extensor and of the flexor carpi ulnaris contained a little 
rather thick pus — this was not sufficient to distend them, it only oozed 
slowly from the incision, and did not appear to amount to more than from 
five to six minims in each. The synovial lining was unaltered, save, per- 
haps, a slightly roseate hue at one part. 

Right ankle. — On both outer and inner side had been during life con- 
siderable swelling, but in the post-mortem room it was found that the 
thick cuticle on inner side of heel had broken (probably after death), 
and a good deal of serum had oozed from it ; thus there was very little 
swelling on examination, but evidence of cellulitis on both sides of ankle 
,and extending round the back. The front was quite healthy, the tendons 
normal. In the sheath of posterior tibial and flexor longus digitorum, as 
they passed over internal lateral ligament, a good deal, i.e., about half a 
drachm, of very thick pus was found. The synovial sheaths were quite nor- 
mal in color. The ankle-joint was perfectly normal, and the somewhat in- 
spissated synovia, which lay at the back from gravitation, was clear and 
bright. 

The pus in the tendinous sheaths contained a few ovoid and dumb-bell 
microzymes ; no rod-shaped bacteria ; the movements of the organisms 
' were, if any, extremely sluggish. A number of minute highly refracting 
spots pervaded the field ; they could only be seen as extremely small dots 
of light, and may or may not have been other micrococci in an early phase 
of development. 

Case XVIII.— On June 15, 1879, 1 removed a small tumor from the inside 
of the thigh of Mr. P., aged twenty-seven. The wound healed, and he was 
apparently well on the 21st. On the 28th a corner of the scar reopened, 
and a little pus escaped. Of this he took no notice till December 1st, 
when, returning from the city, he had a sharp rigor, which was followed 



86 DISEASES OP THE JOINTS. 

at 9 p.m. by another ; the wound became painful, he had no sleep, and : 
very ill. I saw him on the 2d. His temperature was 103.4°, pulse 1 
tongue rather dry and brown. I almost entirely opened the wound, £ 
syringed with carbolic solution (1 in 20), and ordered a scruple of sulp 
carbolate of sodium every four hours. At night temperature 104.7°. ( 
cumference of wound dusky. Passed in a tubular needle, and with inc 
rubber and glass-tube infiltrated the tissues with carbolic acid solution 
per cent. Dressed wound antiseptically. 

December 3d. — Repeated the infiltration, and again at night ; won 
slightly suppurating. Temperature — morning 99.8°, evening 100°. 

December 4th. — Infiltration at night only. Temperature normal 

December 9th. — No fresh symptoms ; felt well. Temperature none 

December 13th. — The wound healed again. He went out on the 12 
but felt a little weak ; he now says he is as strong as ever. 

It is, of course, impossible to say if this attack, left alone, would hi 
developed into pysemia ; it had all the prodromata, and the dusky state 
the wound led me to fear a very bad case. I determined to try the sai 
medicine on a more decisive opportunity. 

Case XIX. — Marianne L., aged thirty-four, admitted into Goldi 
"Ward January 30, 1880. 

She has had nine children ; all have died early of some pulmonary d 
ease. She herself has always been healthy. On January 9th suffered m 
carriage of a five months' foetus. Six weeks ago her leg began to sw 
after a few rigors ; at first the swelling was not painful, but after a til 
pain at the back of the knee and in the groin commenced. 

On admission. — The left leg was very much swollen, its surface shinii 
very white, and too tense to pit on pressure with the finger ; very hot, a 
intensely painful ; the left metacarpophalangeal joint was very painful 
evidently the seat of secondary abscess ; also threatened abscess of the rij; 
shoulder. Tongue moist, with lines of brown on each side of the rap] 
No appetite. Temperature 104° ; pulse over 130, small, very soft. She h 
a profuse blood-stained and highly offensive vaginal discharge. Ordei 
irrigation of the genital passages with solution of carbolic acid (1 in 4 
and to take a scruple of the sulpho-carbolate of sodium, in camphor wat 
every four hours ; brandy ten ounces. 

A few days after admission the size of the limb was certainly less ; 
was measured thus : 

Circumference of ankle 12 inches. 

midcalf 17 

thigh... 24 

February 3d. — She had some diarrhoea — hence fifteen grains of sali 
late of soda substituted for the sulpho-carbolate. 

February 5th. — Vaginal discharge lessened, still considerable evil od( 
the right shoulder and elbow swollen and painful ; has some shivering* 
hardly true rigors. Recur to the sulpho-carbolate. If any well-develor 
rigors occur she is to have ten grains of quinine at once, and five more 
an hour unless the thermometer fall. 

February 10th. — About midnight a sharp rigor. Temperature rose 
104.5° ; came down to 103.2° at 4 a.m. Perspired profusely. 

February 12th. — Better in every way ; took food ; pulse stronger ; co 
plexion clearer. 



ON PrjE.yS.lG JOINT DISEASE AND OTHER AFFECTIONS. 87 

Circumference of ankle 11 inches. 

midcalf. 16 " 

thigh 21£ " 

February 18th. — Has had some rigors, and afterward high temperature, 
but only transient ; the whole temperature line on a lower level. The ther- 
mometer was for two hours down to 99.2°. The pyaamic joints less swollen 
and painful. 

Circumference of ankle 9 J inches. 

midcalf 14f " 

thigh 18£ " 

, Discontinue irrigation. 

February 21st. — Slowly improving ; temperature line still irregular, but 
on generally lower level ; variation from 99.8° to 103°. 
February 24th : 

Circumference of ankle 9£ inches. 

calf. 13^ " 

thigh 15| " 

Eight arm better ; some pain and swelling in vaginal glands. Leave off 
the medicine. 

March 4th. — Still getting better ; left limb nearly normal in size ; glands 
still painful but less swollen ; left wrist and right arm greatly better. 

March 16th. — Convalescent. Free movements in all affected joints ,• 
temperature normal ; pulse firmer ; appetite good. 

March 24th. — Left for the sea-side. 

Remarks. — The foetus had probably died in utero and become putrid. 
The combination of white leg and pyaemia, of the joints marked the case as 
very dangerous, because the internal and, to a very large extent, the com- 
mon iliac vein must have been blocked with septic thrombi. A quantity of 
the poison must, therefore, of necessity be passed into the blood. The aim 
of treatment was threefold. To prevent fresh absorption of putrescent 
matters e loco (irrigation). To destroy or, at all events, prevent multiplica- 
tion of bacteria in blood, by impregnating it with carbolic acid. To obviate 
the immediate effect of an ingress large enough to cause rigors and a high 
temperature, by one or two large doses of quinine given at the moment. 

Case XX.— I was asked on December 17, 1879, by Mr. Ffrench Blake, of 
Victoria Square, Westminster, to see with him Mrs. B., and he gave me the 
following history. 

She was thirty-five years old ; had always been subject to leucorrhosa ; 
had been married about a year, and on November 10th, was confined of 
twins, one full-grown, one still-born— so small and immature that its 
sex was undiscoverable. She went on well till November 24th, on which 
night rigors set in, and the next morning her temperature was 105°. She 
complained much of pain in the back, in the knees, in the left hip and 
shoulder. On the 26th her left, and on the 28th her right, leg became 
much swollen. On the 1st of December her left arm and elbow swelled, 
and the pain in the joint was very severe. The lochia continued, but was 
purulent or muco-purulent, with very offensive odor. Occasional rigors 
had occurred during this period. Lactation continued. 



88 DISEASES OP THE JOINTS. 

When I saw her on the 17th of December, I found both legs mui 
swollen and cedematous ; the joints of the lower limbs were not especial 
affected. The skin was white and glistening, a few surface-veins strong 
marked. There was a swelling about the perineum threatening abscet 
The left arm was swollen, and the elbow-joint, more especially large, w 
very painful ; but, as far as could be made out in the general swelling, t] 
enlargement was peri-articular. The tongue was brown and rather dr 
the pulse 126, weak ; skin hot and, where there was no swelling, dry, whi 
over the swollen parts it was sticky and clammy ; temperature, 103.8 
Constipation ; inertia ; great thirst ; sleeplessness. An aperient was ordere 
and half a grain of morphia at night. As soon as the bowels had acted, t< 
grains of quinine at a dose, and five grains to be given every four houi 
Eight ounces of brandy ; meat essences and strong soups. ' Also irrigatic 
by a long tube, per vaginam, of a three per cent, solution of carbolic acic 

December 21st. — She was considerably better ; the swelling of tl 
limbs had, however, not much decreased ; the elbow-joint was much le 
swollen, and the perineal swelling had subsided. Brandy had been chang< 
to champagne ; she took her food fairly well ; pulse 98 ; temperatur 
100.1° ; tongue cleaner. 

December 25th. — Very much improved ; the swelling of the limbs b 
ginning to decline. Tongue nearly clean ; temperature, 99.6° ; vagin 
discharge had nearly ceased. 

Mr. Blake managed the rest of the case, and reported to me that h 
progress was uninterrupted ; that about January 4th her evening temper 
ture was 99°, morning normal. On the 25th, swelling of the limbs, sa 
slight oedema about the ankles, had disappeared ; on the 28th she got u 
but was still kept in the same room ; by February 1st he ceased atten 
ance, and she was about the house. 

Remarks. — In this case the conditions giving rise to pyaemia are less di 
tinctive than in Case XIX. Mr. Blake was inclined to consider the secoi 
immature foetus as an instance of superfoetation ; but perhaps the origin 
fecundation was double, the one foetus dying early in utero and becomit 
there putrescent. 

At various times Dr. Blackmore, of Hammersmith, has asked me to s< 
the following cases, and has kindly furnished me with abstracts. My ov 
observations at the time of seeiuir the cases are inserted. 

Case XXL — January 31, 1879. — Dr. Blackmore was called to see Mi 
M., aged twenty-six years, married ; has two children, of which the youn 
est is aged eighteen months ; was about five months pregnant. Husbai 
suffering from gonorrhoea of some weeks' duration. Patient complained 
slight pain on micturition, a white discharge, and was generally unwell. 

January 2 5th. ^Complained of pain in both shoulders and the 1< 
elbow ; felt very unwell ; had some slight shiverings. 

February 1st. — The pain had ceased in the joints above named, but t 
right ankle had become very painful, swollen, and tender to touch. 

March 15th. ^1 saw Mrs. M. with Dr. Blackmore, found the ankle swi 
len, white, and tender, could not bear the slightest movement ; the swe 
ing was chiefly peri-articular, but there was some fluid, probably surfa 
pus (p. 29), in the joint. She had lost flesh ; had some pvrexia ; abo 
100° at 4 p.m. 

April 19th. — Premature labor (just over the seventh month). V« 
small female child, which two days after birth suffered from severe pru 



ON PYEMIC JOINT DISEASE AND OTHER AFFECTIONS. 89 

lent ophthalmia ; it died on April 25th. After childbirth the mother's ankle 
got rapidly well — only slight stiffness left, which passive movement soon 
cured. 

Case XXII.— Dr. Blackmore saw, July 13, 1879, Mrs. A. ; married ; one 
child. At the time she was not quite four months pregnant. She complained 
of vague but rather severe pains in all the large joints ; those of the left side 
were more especially affected. In about a week they all got well, except 
the left elbow, which yielded to rest on a splint and other remedies in about 
sixteen days. 

August 11th. — Again sent for on account of a similar affection of the left 
knee, which was much swollen, painful, and tender. In spite of careful 
treatment the disease of the knee continued until October 25th, when she 
was allowed to get up. 

December 5th. — She was confined at the beginning of the eighth month 
of a small female child, which a few days after birth was affected with se- 
vere purulent ophthalmia. 

Case XXHL— August 30, 1879.— Dr. Blackmore saw Mrs. C, aged 
twenty-eight ; she has four children, the youngest being three years old ; 
was not quite four months pregnant. Two days previously felt very un- 
well, had some shivering, and then pain in left shoulder and right wrist. In 
three days the shoulder was well, but the wrist remained swollen and ex- 
ceedingly tender, she could not bear it touched. This continued for three 
months, the part then was placed in a plaster- of-Paris bandage, when it 
became less painful, but remained cedematous. 

January 4th. — Was delivered of a small female child (beginning of 
eighth month), which a few days after birth had very severe purulent 
ophthalmia of one eye. The bandage, which had been taken off, was re- 
placed ; the hand in the interval was quite useless. 

February 20th.— I saw her with Dr. Blackmore. The synovial mem- 
brane of the wrist was lax from former distention, but the chief force of the 
disease had been in the tendinous extensor sheaths. Under narcosis the 
adhesions were broken down. 

February 26th. — The movement of the fingers much less painful, but 
still the hand, excessively weak, had to be kept on a splint, as the muscles 
could not support its weight. She very slowly improved. 

Case XXIV. — Dr. Leonard Sedgwick, of Gloucester Place, asked me, 
August 13, 1877, to see with him in consultation Mrs. A., aged forty-eight 
years, with an affection of the left knee-joint. The following history was 
given me at the time. She had several children, was of lax fibre, suffered 
from considerable leucorrhoBa, and rather free menstruation at each period. 
At the latter part of May she was caught in a sharp shower while at a dis- 
tance from home ; no cab was to be obtained, she got wet through, and had 
in that state to walk home. The catamenia stopped suddenly. Four days 
afterward she had two sharp rigors, followed by considerable pyrexia, pain 
in the shoulders, back and hips ; afterward both knees became painful. 
Gradually all the joints recovered, except the left knee, which remained 
swollen and very painful. Subcutaneous injections of morphia were neces- 
sary to procure sleep. The pyrexia, more especially at night, continued. 
Temperature : morning, 99°, and evening, 102.1°. 

The knee at the above date was swollen, the enlargement being chiefly 
peri-articular— it was white, the limb-segment below pitted slightly on pro- 
longed pressure, the joint was extremely tender, and rather too much flexed. 
In face of the very tender condition, we agreed to apply only a poroplastic 
splint, at present in the same position, to give full doses of qumme, to try 



90 DISEASES OF THE JOINTS. 

gradually to decrease the morphia, and to take the first favorable oppor- 
tunity of administering an anaesthetic, and placing the limb in better 
posture. 

August 29th. — Patient was in every way better ; the nightly tempera- 
ture had declined, and the tenderness greatly decreased. Ether was ad- 
ministered, the knee placed in nearly a straight position, and plaster-of-Paris 
bandage applied. Some grating, not of bone, was felt. An unfavorable 
prognosis as to the subsequent mobility of the knee-joint was given. 

Prom this time the patient went on fairly well, nor did I see her again 
for about five months, during which time another surgeon had endeavored 
to restore mobility, but without success, some painful symptoms returning. 

March 25, 1878. — An anaesthetic was administered, and I bent the knee 
to a right angle ; and afterward both Dr. Sedgwick and I endeavored to in- 
duce her to undergo passive movement, even with the help of an anaes- 
thetic ; but she was very sensitive to pain, disliked repetition of the ether, 
and seemed rather more inclined to be content with what had been gained 
than to undergo further troubled and discomforts. The gain, so far as 
movement is concerned, was not much ; nor, unless the patient be very per- 
severing, can such joints be restored. She enjoys a certain, though small, flex- 
ibility of the limb ; and can walk, though a little stiffly, with barely a limp. 

Case XXV. — J. S., aged nineteen years, was admitted into Charing Cross 
Hospital, under the care of Dr. Pollock, supposed to be suffering from poly- 
articular rheumatism, February, 1880. Some of the symptoms not being 
consistent with this diagnosis, he asked me to see her February 22d. The 
disease had commenced in both the shoulders and the left elbow ; pain in 
the back, too, was very severe. When I saw her, the right hip was alone 
affected ; it was painless, or nearly so when left at rest ; but she complained 
of the slightest motion. The limb was apparently lengthened ; the innomi- 
nate followed every movement of the thigh. There was considerable ten- 
derness, not merely of the joint, but of the more superficial parts, so that 
pinching a thick fold of the integument produced complaint. There was 
some diffused swelling behind the trochanter and in the groin. ' The case 
was evidently not rheumatism, but resembled some one of the absorptive 
joint diseases. It was elicited that during the last menstrual period — twelve 
days before her admission — she had caught a severe cold, the catamenia 
stopped suddenly, and a leucorrhoea, to which she had been subject, had 
also almost disappeared. At my suggestion she was treated with large 
doses of quinine, and extension by weight. The pain gradually declined, 
and she made a very slow recovery by false anchylosis, whose treatment is 
mentioned elsewhere. 

Case XXVI. — Marianne "W. came under my care into Charing Cross 
Hospital, January 2, 1880, suffering from disease of the right knee. The 
malady had commenced a fortnight previously, with pain and swelling of 
the right shoulder and both elbows, preceded by a slight rigor. After three 
days the pain declined in the upper extremities, and both knees became af- 
fected ; after a few days more the left knee got well, but the right one 
worse and more definitely swollen. 

On examination the enlargement was found to be chiefly peri-articular, 
the surface-tenderness was considerable ; the joint was rather white in color. 
This history and condition indicated one of the absorption diseases, and on 
questioning her I learned that she was in the fifth month of pregnancy, and 
that previous to impregnation she had long suffered from leucorrhoea. The 
knee was placed in cotton wool on a Maclntyre splint, and swung on a Sal- 
ter's cradle ; the joint hardly improved, but was perhaps a little less swollen. 



ON PYEMIC JOINT DISEASE AND OTHER AFFECTIONS. 91 

February 22d. — She was prematurely confined (beginning of seventh 
month) ; after this the knee rapidly got better, and in five weeks was quite 
well. 

Case XXVII. — Mrs. L., aged twenty-five years, consulted me concern- 
ing pain and weakness of a knee and of both wrists, March 15, 1877. She 
was pale, slim, of lax fibre, had been married three and a half years. Two 
years previously she miscarried between the fifth and sixth month. Since that 
time a leucorrhoea, from which she always had, more or less, suffered, became 
profuse until about six months previous to the above date, when she again 
became enceinte, and the discharge greatly decreased. On the 3d of the ■ 
month she felt very unwell, was feverish, had slight shivering and severe 
pain in the back. She kept very still lest miscarriage should again come 
on. She appeared to get better, but on the 8th the same symptoms re- 
curred : she had great pain in the shoulders, elbows, and hips, and could 
hardly move ; one or more of her joints were swollen — the disease was con- 
sidered to be acute rheumatism ; in four days more all the joints were free 
except the left knee and both wrists. 

The knee was swollen, the enlargement entirely periarticular, the skin 
white, tenderness to touch considerable. The wrists were very sensitive, 
the pain being at the back ; the joint itself was evidently unaffected, but 
the extensor sheaths were distended, movement was very painful, even to 
support the hand straight with the arm caused her considerable suffering. 
Tongue rather white at the sides, brownish at the back and in the middle. 
Temperature, 103.6°. Pulse 125, small and weak. The conditions of the 
case did not appear to me to agree with the symptoms of rheumatic fever ; 
more especially the odor of the skin and of the breath, not acid, but as of 
mouldy hay, as well as the early remission and recurrence, appeared to 
point to one of the absorption diseases. I treated her on this view with 
rather large doses of quinine, varied as the temperature rose and fell. Irri- 
gation being, under the circumstances, inadmissible,! ordered merely in- 
jection with carbolic acid, and wrapped the joints in cotton-wool, support- 
ing the hand on light mill-board splints. Good diet and some stimulus. 

March 31st. — Certainly better. The tongue was cleaner, temperature 
rarely rising above 100°, but all the affected joints were still very weak, 
somewhat swollen, only painful on movement. Flying blisters (not vesi- 
cation) to the wrists alternately. 

April 13th. — Blisters having been used alternately to the knee and 
wrists, they became less painful, and at above date could be moved a little. 
Ten grains of sulpho-carbolate of sodium every four hours. This being the 
first case in which the drug had, so far as I know, been used internally as- 
an aseptic, I was, in the then condition .of the patient, very cautious. 

April 28th. — The patient improved considerably ; after three days the 
dose of the drug was increased to fifteen grains ; on the 24th she was al- 
lowed to get up, and at date could, while supported by her husband, walk 
without pain. 

July 26th. — Mr. L. came, requesting me to return with him. He in- 
formed me that on June 6th his wife had been confined, child healthy, and 
all went well. She had nursed the infant for six weeks, but then the supply 
became less, and the baby occasionally sick after taking the breast ; she 
left off suckling by rapid degrees, but without pain or trouble. Three days 
ago she had headache and was sick, took some purgative, seemed a little 
better, but on the evening previous to sending had been shivering and ail- 
ing ; during the night very hot and restless. 

I found her complaining of headache and general malaise, more espe- 



92 DISEASES OP THE JOINTS. 

cially of pain in the hips and lower part of the back ; she had a great sense 
of disquiet and oppression, said she never felt so ill before, and was sure 
she should die. Her skin was very hot, but not particularly dry ; she had 
not menstruated since her confinement. The breasts were rather full ; a 
little milk oozed on pressure. Attributing her condition to a too sudden 
cessation of lactation, I inserted liq. atropine with a fine camel-hair brush 
into any milk which I could see, gave a smart purge and some effervescent 
ammonia. She was rather better up to 

August 2d. — A smart rigor ushered in a return of pyrexia. "When I saw 
her the temperature was 104.4° She had intense pain in the right knee 
and both hips. I treated her with large doses of quinine. 

August 11th. — The right knee and hips were no longer painful, but for 
five days the temperature continued very high, from 100° to 102.5°. On the 
15th the left knee became swollen and tender ; it was at this time the only 
joint affected, and shortly was exceedingly painful — much swollen — and was 
put in a plaster-of-Paris splint. The sulphp-carbolate of sodium was sub- 
sti' Lted for quinine. 

August 26th. — Somewhat profuse menstruation began. 

August 9th. — The menstruation continued nine days, during which time 
she got better ; the temperature declined. 

The patient recovered slowly, the knee remaining some time stiff, and 
was twice flexed and moved under the influence of ether, and though quite 
able to move it in all desirable directions, she never recovered the full power 
of flexion enj oye d by the other, nor could she place it quite straight. 

Case XXVHL— Dr. Churchill, of Chesham, sent to me, April 4, 1874, Mrs. 
D., aged thirty-nine, married, always enjoying good health until shortly 
after the Christmas preceding, when she was severely attacked by enteric 
fever. She had been almost completely unconscious for five days. When 
getting convalescent it was observed that the left limb was considerably 
shortened, and Dr. Churchill, when she was able to undergo examination, 
diagnosed dislocation of the hip. It was impossible to trace this occur- 
rence to any particular time or epoch of the illness. As soon as she was 
able to travel she was brought to town, and I was able to confirm Dr. 
Churchill's diagnosis. It was impossible to replace the head of the'bone in 
the acetabulum ; but the movements of Bigelow's method gave her a far 
freer mobility, and although she could, when leaving, walk very much 
better than those who have suffered unreduced traumatic luxation, there is 
no doubt but that considerable lameness must remain through life. 

Case XXIX.— In the latter end of October, 1879, Mr. Wilcox, of Ayles- 
bury, sent me a young lady, aged sixteen, on account of hip-lameness. On 
February 7, 1879, she had been, in common with other members of her 
family, attacked with typhoid fever. Her illness was very severe ; she lay 
perfectly insensible for six weeks, swallowing and performing the other 
functions of life unconsciously. She was, however, kept alive by assiduous 
nursing, yet in spite of the utmost care the skin over the sacrum sloughed. 
About the time when prospects of saving life became a little better, Mr. 
Wilcox observed that the right lower limb looked short, but the patient 
was far too ill either to be thoroughly examined or subjected to treak 
ment for the joint-affection. When at last, thirty-four weeks after the 
commencement of her illness, she could be moved, Mr. Wilcox sent her 
to me. 

An examination showed the femur to be dislocated upon the dorsum 
ilii ; the limb was nearly three inches short, the foot inverted, and the 
trochanter lay high above Nelaton's line. In correspondence with Mr. 



ON PYEMIC JOINT DISEASE AND OTHER AFFECTIONS. 93 

Wilcox, who had come to the same conclusion, it was agreed that we should 
endeavor to replace the bone ; accordingly, 

October 22d, chloroform having been administered, we first endeav- 
ored, by manipulation, to reduce the dislocation. Numerous adhesions 
gave way with audible rending, but the head of the femur would not enter 
the acetabulum. The pulleys were then applied, with equal unsuccess. I 
believe the head of the bone lay on the cavity, but probably this latter had 
contracted during the interval. The patient, who had been lying upon a 
mattress on the floor, was put to bed, and weights were applied. Later in 
the evening £ grain of morphia was given ; this soporific, of which she had 
already taken, during her illness, a number of doses, was occasionally ad- 
ministered during the rest of the case. 

She stayed in town a fortnight, during which time extension was used 
with the hope of procuring greater length of limb. Passive movement was 
from time to time attempted, but the patient was feeble, very sensitive, and 
but little in this way could be effected. On November 8th she returned 
home but little benefited. 

Mr. Wilcox writes that " Mary W. did not leave her bed until sixteen 
weeks after the commencement of her illness. It was when she attempted 
to stand that I first noticed the shortness of her leg. While she remained 
in bed nothing led me to believe that there was anything wrong about her 
hip, although the prolonged high temperature caused me to examine her 
more than once for some reason for it. The conclusion I came to was that 
the temperature was high in consequence of extensive bed-sores." 

Her left leg is now thirty-one inches in length, from ant. sup. spine of 
the ilium to point of external malleolus ; right, thirty-three inches. The 
foot is' slightly inverted, with very diminished power of eversion. She walks 
short distances without crutch or stick. Power of walking increases slowly. 
She gains steadily in weight and strength. 



CHAPTER V. 

STRUMOUS SYNOVITIS. 

Pathology. — We began our account of synovial disease with the exami- 
nation of an acute simple affection, and it was pointed out that, as the in- 
flammation subsides, it merges into a less and less severe condition, which, 
if the constitution be healthy, passes more or less rapidly away. But if any 
morbid diathesis be present, it is apt to influence and prolong the inflam- 
matory acts, to impress upon them its own peculiarity and type. Thus, a 
local manifestation of constitutional vice may be traced back to some in- 
jury, bringing on an acute attack, which up to a certain point was easily 
subdued, but beyond that point was exceedingly obstinate. Other chronic 
maladies have no such definite origin, but begin, if in our patient's remem- 
brance, with some intangible history, or, as he may say, "of itself." The 
diathesis which most frequently gives rise, thus out of the vague, to chronic 
joint disease, is struma ; the same cachexia possesses only a slighter pre- 
eminence in adding a chronic continuation to an acute inflammation. 

Some objection has been of late years taken to the name " strumous " 
as applied to the very chronic joint-maladies about to be considered. Mr. 
Holmes 1 in particular would deny, or at least "question," the propriety of 
this very convenient and common appellation : apparently for two reasons, 
that, when the affected part is removed, the disease does not constantly, nor 
indeed often, recur ; and that tuberculosis does not always, nor very fre- 
quently, arise in children thus affected. I cannot but think' that two errors 
of ratiocination underlie this argument : firstly, the idea that tuberculosis 
is a necessary sequel and accompaniment of scrofula ; secondly, a want of 
definition as to what we mean by scrofula or struma. If, for instance, we 
accept Billroth's version, a disposition to chronic inflammation of the mem- 
branes, bones and joints, in which the inflammatory process may lead to the 
development of granulation, suppuration, or caseous degeneration," '' I do 
not see how we can exclude the fungating synovitis from strumous disease. 
Or the same pathologist's description in another place : " We assume a 
scrofulous diathesis for those cases in which a slight and transient irritation 
of some part of the body sets up a chronic inflammatory process, which not 
only outlasts the irritation, but spreads or continues independently of it, 
which usually results in suppuration or caseation, and rarely assumes the 
form of a pure hyperplasia." 3 With this latter description I thoroughly 
agree, and therefore must accept the very occurrence of this particular form 
of inflammation as symptomatic of struma ; nor is Mr. Holmes's objection 
comprehensible,. unless to it were appended what his peculiar (for to me it 
seems peculiar) definition of scrophulosis or struma may be. Moreover, the 

1 Surgical Treatment of Children's Diseases, p. 434. 

2 Billroth's Surgery, Sydenham Society Ed., vol. ii., p. 107. 

3 Billroth's Scrophulosis and Tuberculosis : Pitha's and Billroth's Handbuch der 
Chirurgie, Bd. i., Abth. 2, Heft 1, p. 311. 



• STRUMOUS SYNOVITIS. 95 

minute morbid anatomy of the diseased tissue being the same, whether one 
or many joints be affected, excludes the idea of marking a difference in their 
appellation. The fact that tubercles have been found in the inflammatory 
tissue, that many children subjects of this joint-affection die of pulmonary • 
or meningitic tuberculosis, more than justifies me in continuing the term 
strumous synovitis for this particular class of joint disease, although quite 
aware of the fact that such synovitis may be occasionally the only visible 
morbid result of the diathesis. 

Case XXX.— Charles , aged ten, was admitted under my care into 

Charing Cross Hospital, April 25, 1872, with disease of the knee-joint. He 
was a small child, very thin, and had evidently been insufficiently fed ; the 
right knee bore all the marks of strumous synovitis. He had been only 
twenty-three days in hospital when cerebral symptoms supervened, and he 
died shortly after of tubercular meningitis. I examined the joint very care- 
fully, making first a cut across the lower part of the thigh, from eaeh end 
of which an incision extended to the tibial tuberosity, about half an inch 
from the side of the patella. The flap had to be dissected off very thin, be- 
cause close under the skin in some places, in others a little deeper, the 
knife discovered a translucent, gelatinous substance of a light yellow hue, 
which took the place of the peri-articular and synovial tissues, obliterated 
or filled up the subcrureal sac, and greatly encroached on or filled the cav- 
ity of the joint. Some white lines, as of fibre-tissue, permeated this gela- 
tinous mass, and a few small, tortuous vessels were seen running, and ow- 
ing to its translucency could be followed a little way into its thickness, 
where some of them split up into a lash of long, winding twigs. 

The external ligaments, including the lateral, were found not so much 
sunk in, as merged into and continuous with this tissue. They were, more 
especially on their deep surface, commingled with the morbid tissue, which 
could neither be dissected from them with the blade, nor pushed off them 
with the handle of the scalpel without breaking at innumerable points. 

This tissue being incised in the same direction and to the same extent 
as the skin, was turned back so as to expose what little remained of the 
joint-cavity (the subcrureal sac was entirely filled up), which contained a 
thin pus mixed with many larger and smaller flocculi. This fluid showed 
a strong tendency to separate into a turbid liquor puris and a thicker, 
more opaque sediment. The walls of the cavity were uneven and nodular, 
rather more pink than the other parts of the tissue ; they encroached on 
the cartilages, so that on the patella only an irregular oval, about the size 
of a sixpence, remained uncovered ; on the inner condyle of the femur a 
similar surface, oval with the long axis across (from side to side) ; on the 
outer condyle a very small part was bare. No cartilage on the tibial parts 
was exposed in this position of the joint, namely, considerably flexed. The 
portions of tissue intruding on the joint-surfaces were rather thin, in 
places so much so that the sheen of the hidden cartilages could be seen 
through them ; they were digitated or serrated, and in the prolongation 
long, wavy" vessels showed as tortuous lines. By opening the cavity farther 
and more completely flexing the joint, these dendriform growths* were 
drawn away from the cartilages, to which they in spots adhered, and were 
seen to consist of vascular tufts surrounded by gelatiniform tissue. 

The same was observed on the patellar surface. Around the patella, 
"whence this outgrowth chiefly sprang, as at the sides of the inner joint- 
surface, the tissue was rather redder than elsewhere. The menisci had dis- 
appeared ; they had simply become part of the gelatinous mass. The cru- 



96 DISEASES OP THE JOINTS. 

cial ligaments had all but vanished ; a few scattered white fibres lying in 
the pinkish growth was all that remained of them. 

The points where the morbid fringes that encroached on the cartilage 
had adhered were easily found, since in drawing those growths away a 
little tuft of the pink tissue was left behind ; these were seen to have in- 
truded into little roughened holes that were partly filled by these tufts, 
partly by fibrous debris of the cartilage, and the two structures had con- 
tracted close union. In one spot on the inner condyle, which was not cov- 
ered by any synovial outgrowth, was a shallow, irregular ulcer, the edges 
of which were sharp and well defined, while its base was yellowish, dull 
and pulpy. 

The microscope showed the bulk of this yellow or pink tissue to con- 
sist of innumerable round cells and bare nuclei, with here and there a tract 
of fibre-cells running through it, sometimes surrounding long, small arte- 
ries ; also among them were fibres of evidently older growth, which I took 
to be partly destroyed lymphatics. 

The microscopic characters of the cartilage will be described in a chap- 
ter devoted to changes in that structure. 

Examination of disease somewhat further advanced may also be de- 
scribed. 

Case XXXI. — Phoebe H- •, aged nine, was admitted, under Mr. Han- 
cock's care, into the Charing Cross Hospital, April 22, 1856, with a far ad- 
vanced strumous disease of the knee. Owing to the state of the patient's 
health, the limb was amputated on May 3d. 

May 3d. — I examined the limb. On dissecting up the patella and open- 
ing the joint no cavity could be seen, except two small spaces, whose posi- 
tion and size will be described immediately. The whole space between the 
skin and these cavities appeared converted into a light brown jelly, inter- 
sected here and there by thin, white, .fibrous, glistening bands, marked by 
small wavy vessels, and spotted by specks of extravasated blood, of a hue 
somewhat darker than that of the veins. The interarticular cartilages could 
not be found ; the external ligaments of the joint were only visible as scat- 
tered white fibrillse separated from each other by the gelatinous tissue ; the 
crucial ligaments were in a similar condition. On each side of these latter 
structures, and of the mass of jelly which enclosed them, was a pyriform 
cavity ; the larger part, which would admit the finger, being situated in 
front, some distance from the patella, the smaller end running backward 
and a little outward ; they were in shape like the lateral ventricles of the 
brain without the descending cornua ; they contained pus, and the smaller 
end communicated with abscesses, under the corresponding heads of the 
gastrocnemius muscle. There appeared to be no communication between 
the cavities, nor between the abscesses. The gelatinous matter was in 
places immediately under the skin, and was generally about two inches 
thick ; not so much at the back, more at the side of the patella. There 
was no trace of articular cartilage on any of the joint-surfaces ; but the 
jelly-like material appeared to rise equally from the synovial membrane and 
from the otherwise bare cancelli of the femur, tibia, and patella. A section 
across the ligamentum patellse presented the cut ends of the fibres sepa- 
rated from each other by the same gelatinous tissue ; they seemed swollen 
and sodden. Examined by the microscope, this substance was found to . 
consist of a number of nucleated cells — round, oval and fusiform, of bare 
nuclei, and of granules. Most of the fusiform cells were arranged in lines, 



STRUMOUS SYNOVITIS. 97 

three or four cells broad ; the cells lying end to end, or, rather, with their 
thin ends just overlapping the similar extremities of their neighbors to the 
right and left. These lines of cells crossed and recrossed each other, form- 
ing irregular spaces, in which the round cells and other constituents of the 
tissue were stored. The white bands presented simply a fibrous appear- 
ance, and were much tougher than any other part of the tissue. 

These examinations may well be taken as our starting-point in the de- 
scription of the disease. I need only premise that they depict cases of very 
decided type, strumous synovitis, k<xt Zfrxrjv, of which we see, both in hos- 
pital and in private practice, an immense quantity. It is the malady whose- 
description by Wiseman gave the name, while morbid anatomy was in its 
infancy, of "white swelling" — tumor albus — to almost every chronic joint 
disease. It is also the malady described by Sir Benjamin Brodie as a 
"morbid change of the synovial membrane," and is named J'ungose Gelen- 
kentzlindung by Billroth ' and Volkmann/ tumeur fongueuse, by Velpeau,* 
Bonnet, 4 Bichet, 6 and others. 

The appearances above described, which distinguish this disease from 
other chronic maladies of joints, consist in the large development of a 
semi-solid or gelatinous material, which slowly permeates, invades, and in- 
deed, in its fullest development, substitutes itself for every articulation tis- 
sue. This growth, as I pointed out in 1859, 6 is simply granulation, and 
since then the word and the view have been adopted by pathologists, Eng- 
lish and continental. All inflammations of connective tissue are consti- 
tuted, or at least accompanied, by more or less plentiful germination of 
cells, chiefly, probably, of tissue-cells. 7 This cell-proliferation was first 
signalized by Virchow in his " Cellular Pathology." It is not absolutely the 

- first act of acute, but is certainly the most important part of chronic in- 
flammations. In a simple chronic inflammation the affected tissue becomes 

.hardened and enlarged by the accumulation of cells, to over-repletion, in 
what were previously spaces of the tissue, while the histological elements 
themselves become altered by the metamorphosis of their constituent cells 
into mere proliferation-tissue cells. In a certain time, if the action sub- 
side, the older parts resume their former state, the fresh growths consoli- 
date, form new fibrous tissue, and the part gets well, leaving behind it only 
a certain amount of thickening, which may itself in due course disappeat. 
Inflammation, modified by struma, goes through precisely the same pro- 
cesses of cell-germination and growth, but there it stops for an indefinite 

, time. The new material does not harden into tissue, nor indeed does it 
for a long period take on any fresh act except increase ; it simply remains 
an abortive or embryo tissue. The condition, save that it occurs beneath 
the skin, is precisely the same as that of an indolent ulcer, which neither 
heals nor enlarges, but simply granulates. In strumous synovitis the cell- 
growth or granulation arises both from the free surfape of the synovial 
membrane, and from the attached, or rather from the fine subsynovial tis- 
sue. The former of these commences by a slight increase in size of the 
fringes, so that the inner surface of the membrane is visibly roughened, 

1 Chirurgische Pathologie. 2 Krankheiten des Bewegungsapparat. 

3 Dictionnaire en xxxvols. 4 Maladies des articulations. 

6 Sur les tumeurs blanches. Hiiter calls different degrees of this disease synovitis 
hyperplastica granulosa (s. f ungosa) and synovitis hyperplastica tuberosa (s. papillaris). 

'See Beale's Archives, vol. ii., No. 5. 

1 See p. 27 for the reasons of my belief concerning the small part which errant 
white corpuscles play in inflammation of synovial and areolar tissues. 
7 



98 DISEASES OF THE JOINTS. 

like the mucous coat of the intestine, or a granular conjunctiva. After 
time a still further increase takes place, but the villi do not assume the den 
dritic or arborescent form of growth so marked in other disease. In th 
less severe cases they throw but digitations, or membraniform expansions 
which creep over the cartilages with after-results to be soon described. 1 
the more characteristic strumous forms several fringe-processes uniting 
form thicker nodular projections of conical shape, with apices intrudinj 
into the cavity, and bases forming part of the general thickening. Th 
difference is one of degree merely, not. to my mind requiring distinction 
in nomenclature. The secretion from a membrane so altered is not, c 
course, normal ; its variations will be described immediately. 

In the Museum of the Charing Cross Hospital are many excellent sped 
mens of this sort of growth. It must, however, be remembered that th 
fine translucent appearance is entirely lost by preservation in spirit, and 
mere nodular yellowish vegetation, incrusting the cartilages more or less 
remains. Also in the College of Surgeons' Museum are some excellen 
preparations. 

The growth from the peri-synovial tissue increases outward, and grad 
nally involves all the articular circumference ; the synovial basement-mem 
brane, caught as it were between these two, is merged into and disappear 
in the growth. The two parts, that from within and that from without- 
the wiima — then form but one mass, traversed by the ligaments of th 
joint. These themselves do not, however, remain healthy : the commo: 
areolar tissue which permeates them, binding together their fibres, cany 
ing the capillaries and lymphatic rootlets, germinates, and forms granule 
tions in their very substance, separates or loosens their fibres, starving th 
fibrillse, which fall into fatty degeneration, and are at last absorbed, so tha 
the bones, forming the joint, become movable in directions not intended b 
nature, and may even be partially or totally dislocated by muscular coe 
tractions. All this, and I feel that I can hardly too often repeat the fact, i 
not in itself different to the first acts of a common inflammation ; only it 
amount and persistence are different ; for whereas in a healthy act part 
would cease to germinate, and would either solidify or degenerate, thi 
form of inflammation only continues the vegetative act, resulting in trans 
formation of all soft parts around the bones into a jelly-like, pink, transit! 
cent mass.' 

Under a good power of microscope this tissue is seen to consist in it 
more recent parts almost entirely of round and oval cells, also of bare nu 
clei ; it is precisely the same as granulation from a wound or ulcer. Th 
older portions contain also a number of fusiform, even of fibre-cells, whic! 
arrange themselves, overlapping their thin extremities, into lines tha 
intersect each other, and divide the more embryonic tissue into spaces o 
loculi. This is a commencement toward the formation of areolar tissue 
the lines of fusiform cells are more or less abundant and clearly markec 
more or less scanty and imperfect, according to the more or less complete! 
unhealthy nature of the case. In the former condition a tolerably distinc 
attempt to form areolar tissue is made; the cells in question are long i 
proportion to their breadth, even become mere cell-fibres, more opaqu 



'Koster (Virchow's Archiv, Bd. xlviii.) has described in this tissue the presence ( 
small miliary tubercles. I differ from that authority with great caution and relm 
tance, bu; am bound to say that I have never been able to convince myself that tl 
little specks were other than various forms of degeneration, fatty and suppurativi 
occurring in the substance of the new-growth. 



STRUMOUS SYNOVITIS. 99 

and whiter than the rounder examples. In the latter the cells are not far 
from the oval shape, and the attempt to form fibre is but very slightly 
evidenced. Between these two conditions many intermediate gradations 
exist. 

This whole process of cell-formation described above, at perhaps too 
great a length, is called "tissue-vegetation" (Gewebs vegetation) by Boki- 
tansky, who gives the subjoined account of the process : 

" A second portion of the products of the inflamed tissues (serous mem- 
branes), the ' G-ewebsvegetation ' (tissue-vegetation), must be distinguished 
from exudation, and arises in ' consequence of effusion into the subserous 
tissue. It consists in a growth from the basement-membrane of masses of 
cells, in a vegetation of round, oval, and fusiform cells which dissolve them- 
selves into a hyaline mass and become areolar fibrillse. Examination of 
this material Qn serous membranes offers the most and richest explana- 
tions on the origin and development of this .vegetation. On the serous 
membranes arise layers of round, oval, and fusiform cells of Jy millimetre 
in diameter, with nuclei of T J „ millimetre. They grow out of the mem- 
brane in the form of a delicate villous covering, papilla-like granulations, 
or of branching and anastomosing folds, and give to the surface its well- 
known dull, velvety appearance. At the same time the serous membrane 
loses its fibrous texture, and assumes a hyaline, gelatinous consistence. 
The vegetation forms itself into a simple or an interrupted lamella, or into 
a network, and these again give origin to new masses of cells, of fringes, 
papillse, or bands. In this way are piled up simple or looped lamelke or 
network ; these last intermingle freely, whereby a change into fibrous con- 
nective tissue advances from the older to the newer strata. The nutriment 
for this continuous vegetation is derived chiefly from the vessels advancing 
into it from the serous membrane ; but some portion of it may be borrowed 
from the exudation contained in the cavity within the growing formation. 
The growth, when the blastema (histogenetic material) dissolves, is reduced 
into a serous fluid." — " Lehrbuch der pathologischen Anatomie," Band i., 
,S. 136. 

Thus far the morbid actions consist entirely in the heaping up of new 
•elements ; they may be called the generative or vegetative processes, and 
■constitute that portion of the disease, which in the first edition of this 
work was called the first stage, a division which has been adopted by Volk- 
mann and others. Before passing on to the other stages, it will be well to 
examine the result of these actions, namely, more or less complete meta- 
morphosis of synovial and peri-articular tissues into gelatinous granulation 
material. The very reduced cavity is filled with a pus, which is generally 
not quite laudable, having abnormal tendency to separate into liquor puris, 
floating cells, and flocculi. The adventitious tissue attains in different 
specimens to various degrees of thickness, previous to the commencement 
of any second phase, i.e., of any affection of cartilage or bone, of any ex- 
ternal or interstitial abscess. I have often examined joints of children in 
"which this embryonic tissue, in places from one inch and a half to two 
inches thick, occupied the whole space between the central cavity and the 
skin ; in which the cartilage remained entire, and only somewhat dulled on 
the surface. In this tissue in certain cases there would be an abscess com- 
municating or not with the joint-cavity ; in others no interstitial suppura- 
tion had taken place. I have also examined joints affected with the same 
disease, in which changes in the cartilage and in the new tissue, one or 
both, had occurred ; that is to say, the second and third stage of the dis- 
ease had commenced before the adventitious material had attained any 



100 DISEASES OP THE JOINTS. 

Tery considerable thickness, and before it had so entirely invaded and r< 
placed the normal tissues of the part. 

These variations depend in. part upon the sort of joint ; at an articuls 
tion, such as the knee, shoulder, or even "elbow, the large bones offer longe 
resistance to invasion, than do the small bones of the carpus or anterio 
part of the tarsus, whose nutrition is much affected by false growths aroun 
them, and whose proportion to the bulk of synovial tissue is so much less 
Also in part upon the age of the patient, or, in other words, upon the cor 
dition of the epiphysal end of the bone. If the nucleus be still small, am 
a considerable thickness of cartilage (it can hardly be called articular) sub 
tend the joint, changes of that material are postponed till a later date i 
the history of the disease. 

Second Stage. — At an uncertain period of the vegetative action in th 
synovial membrane the cartilages become diseased. The changes takin| 
place in cartilage will be fully discussed in a future chapter, but it will b 
necessary to say a few words on the subject here. Many years ago, i 
scattered papers, 1 as well as in the first edition of this work, I pointed ou 
that ulceration in cartilage, occurring during the course of inflammator 
joint disease, is itself the result of inflammation in that tissue, not, as wa 
previously believed, of an eroding action by the false membranes developei 
from the synovial membrane. This view is now so generally held, that it i 
not advisable to go through the system of proof, which then was necessary 

The ulceration of cartilage may occur in two forms, one very rapid, an< 
another much slower. The two are not unfrequently present in differen 
points of the same cartilage, or in different cartilages of the same joint, am 
the appearances vary considerably in each form. In the slower process th 
first appearance is a slightly elevated spot, where the structure has lost it 
polish and its translucency, assuming also a light yellowish tinge. A sectio] 
perpendicularly through one of these spots shows it to be conical in shape 
its base at the free surface, its apex deep in the cartilaginous structure 
and more or less close to, touching or truncateu by the bone, according t 
the age of the ulcer. 

If the section be examined by the microscope, it will be seen that, a 
the diseased part, the cartilage-corpuscles have become much larger, ani 
the cells contained in them have also greatly increased both in size an< 
number, each one being provided with a number of nuclei, and having be 
come more or less granular ; some of them also contain oil-globules. 

This disturbance of the usual condition is in its earliest stage below tli 
part which looks to the naked eye diseased ; but becomes more and niori 
marked toward the free edge of the section, where many of the swolle] 
corpuscles lose their distinctness of outline, and even coalesce. The inchs 
tinctness of outline is owing, according to Eokitansky and Weber, to th 
gelatification of the hyaline substance, but this assertion requires proof ; i 
is certain, however, that during and in consequence of this alteration i) 
the cells, the hyaline substance becomes obscurely granular, striated, an< 
fibrous ; it also frequently assumes a yellowish color. ' 

The free surface of these unhealthy spots, examined by the microscope 
presents a rough uneven aspect, full of irregular depressions and equall; 
irregular elevations. The depressions are formed by the rupture of swollei 
corpuscles, and the elevations, which are fibrous or velvety, by the projec 
tion of the altered hyaline substance. Scattered over this surface are man; 



1 On the Articular Cartilages, British and Foreign Quarterly, October, 1859. Ulcera 
tion of Cartilages, Edinburgh Monthly Journal, February, 1860. 



STRUMOUS SYNOVITIS. 



101 



cells, with several nuclei, and more or less granular, some of which are un- 
dergoing further changes, becoming fusiform or even stellate. 

These spots may occur in any part of the cartilage, either at the edge 
overlapped by the false tissue or in the middle of the joint, where two sur- 
faces of cartilage are in actual contact, no false tissue intervening, or in any 
part of the encrusting material which granulation has not yet reached ; 
again, under this tissue the cartilage may remain for the most part healthy, 
and in these places the whole zone of false tissue, with its ramifications and. 
its plexus of vessels, can be lifted entirely from the cartilage, wherever that 
structure has remained sound ; but, wherever it has undergone the altera- 
tions already described, there occurs a peculiar adhesion between the two 
tissues in a manner now to be explained. As the ulceration continues it 
approaches more and more the attached surface, the hyaline substance be- 
comes fibrous over a greater area and in greater depth, the corpuscles in- 
crease in size and burst, discharging the cells into the surrounding struc- 





Fig. 7. — Section of strumous ulcer of carti- 
lage maguified 500 diams. 



Fig. S.— Section of cartilage becoming 
slowly transformed into areolar tissue. 



ture, in which many apparently empty rifts and chasms are perceptible. 
The direction of these cracks appears peculiarly arbitrary ; some of them 
run with the fibres, others directly, others obliquely, across them ; many 
of them terminate at either end more or less abruptly ; but some of them, 
and this of course depends upon a fortunate position of the section, are 
seen to diverge from a centre larger than any one of the branches, which 
are themselves larger near the centre than toward their termination ; the 
whole shape is like that of a crack or star in a pane of glass, produced by 
striking it with any small object. On examining this stellate rift more 
closely, it will be seen to be granular throughout ; on applying dilute acetic 
acid the granules fade, and in the centre of the star one or more nuclei will 
become evident. This apparently empty space is therefore not empty at all, 
nor is it a series of cracks in the hyaline substance, whose directions are 
accidental. It is a stellate cell developed from one of the cartilage-cells, 
that had been scattered from a ruptured corpuscle, and which is in form 
and size exactly like one of the cells so characteristic of areolar tissue. In 



102 DISEASES OF THE JOINTS. 

fact, the cartilage has slowly undergone a transformation into a form c 
nascent areolar tissue, and at the same time there has occurred, betwee 
the structure thus formed and the similar material growing from the sync 
vial membrane, an adhesion or interweaving which becomes more an 
more intimate until at last it is mere continuity. It is this condition whic 
led Mr. Aston Key ' to ascribe the ulceration of cartilage to the action of 
rodent tissue growing from the inner surface of the synovial membrane 
which gradually absorbed the cartilage, supposed in this instance to b 
perfectly passive. A clearer knowledge, however, and a closer study of th 
phenomena lead us tb the truth, that the cartilage is ulcerated by an actio: 
or actions of its own, and thus we come back as nearly as possible to Si 
B. Brodie's opinion. This celebrated surgeon so clearly saw that this wa 
the case, that in order to explain its possibility he had to insist on the pres 
ence of vessels, because non-vascular parts were, in his time, supposed in 
capable of inflammation. As, however, it can now be certainly afflrmei 
that any part which is capable of nutrition is also liable to inflammation, i 
can, I submit, be no longer denied that cartilage is liable to be inflamed 
and consequently ulcerated, whenever an inflammatory disease attacks tb 
other structures of the joint." 

It has been said that during this process many cartilage-corpuscles burs 
on or near the surface, discharging the cells among the fibres of the altera 
hyaline substance, and into the joint-cavity. AVe have in the present char, 
ter traced what becomes of them in the former situation. As to what hap 
pens to them in the latter nothing certain can be known ; it is probabl 
that the greater number fall into fatty degeneration and dissolve awaj 
Others no doubt contribute their quota to the pus in the cavity. 

In a quicker form of ulceration (see Chapter XIII. ), loss of substanc 
is so rapid, that a previous stage is barely discoverable ; the. hole in th 
structure is under such cireumstances bounded by clean-cut edges, as thoug 
a piece had been cut out with a knife or punch. Sometimes these edge 
are remarkably regitlar, more often peculiarly irregular. As a rule, in thi 
form of ulceration the articular lamella disappears with or immediate], 
after the cartilage. 

Such rapid ulceration nearly always occurs at those parts of the carti 
lages which are in contact with each other, for, as already said, and agai 
to be mentioned, the mutual pressure of the joint-bones is greater in dis 
ease than in health. Especially liable to this ulceration are the cartilage 
of joints which have been allowed to remain in some malposture, either be 
cause the pressure is thereby increased, or because the point of pressure i 
an unaccustomed and abnormal one. We may often find in such places tha 
the cartilages have entirely succumbed to rapid ulceration, while elsewher 
they will be either non-eroded, or only beginning slowly to give way. 

The overaction of the cartilage-cells must call for additional nutriment 
in other words, for additional blood-supply. The hypersemia, the visibl 
sign of this increased nutrition, is found in the vessels of the cancelli, whic 
immediately underlie the articular lamella. I have already shown that th 
acute ulceration of cartilage brings with it a redness and fulness of thi 
part, easily seen on sawing through the bone longitudinally. It shoulc 

1 Med. Chir. Trans., vol. xix. 

2 See ray papers On the Articular Cartilages, in the British and Foreign Quarterl; 
October, 1859, and in the Edinburgh Monthly Journal, February 1860, since which, an 
since the appearance of the first edition of this work, the views of scientific surgeoi 
on this subject have become consonant with those then enunciated. 




STRUMOUS SYNOVITIS. 103 

when possible, be checked by examining the fellow-bone of the opposite 
side, but it is generally well enough marked to be unmistakable. This hy- 
persemia, especially as pressure between the bones continues, readily turns 
to inflammation at that spot, and this is one of the routes whereby synovi- 
tis spreads to the cancellous bone-tissue. The ostitis is followed by for- 
mation of granulations, and these occurring in the same person and con- 
stitution as the synovitis, have the same tendency to remain embryonic 
rather than to proceed onward to tissue-formation. The cancellous cavities 
become filled with gelatini- 
form tissue exactly similar 
to that of the synovial mem- 
branes ; the cancellar plates 
also inflame, soften, and are 
many of them absorbed in- 
to a like tissue or become 
carious ; the articular lam- 
ella is detached. If this de- 
tachment takes place at a 
spot to which cartilage is 
still connected, that portion 
falls into the cavity, or lies 
loose among the granula- 
tions. We often find among Fig. 9._Upper surface of tibia. Ulceration of cartilages. 

the altered tissues, such 

pieces lying adrift ; on their deep surface a sabulous roughness, the re- 
mains of the lamella, which came away with the cartilage, is to be felt. But 
the cancellar cavities may be laid open in another way, by the formation of 
small holes underlying little cartilaginous ulcers, and the granulations may 
sprout through them, and, invading more and more substance of the bone 
and cartilage, increase in size until two or more of these holes run together, 
when a larger breach of surface will ensue. In either way the cancellous 
cavities are laid open to the joint, or rather to the tissue which has taken 
its place, and the granulations from the bone mingle with those of the soft 
parts. 

The result in either case is the same, namely, two (in certain joints 
three) bones with unsealed ends are united more or less loosely together 
by a soft granulation-tissue, which occupies all the space from the subcu- 
taneous tissue inward, and passing into the unclosed bone-ends fills also 
the cancellous cavities. In advanced cases all else has disappeared : there 
are two tubular bones, conjoined by a quantity of embryonic tissue enclos- 
ing a central cavity, surrounded by skin and a certain thickness of subcu- 
taneous tissue. 

Even the cortex of these bones, often very much thinned, shows signs of 
very similar change ; for a certain distance from their ends their tissue will 
be rarefied, the vascular foramina will be greatly increased in size, making 
in or on the surface furrows and gaps, which are filled with the same gela- 
tinous tissue, while even the structure which separates these breaches will 
be softened — osteoporosis and osteomalacia. Beyond this distance, what- 
ever it may be, the osseous surface is usually roughened by a few small 
osteophytes. These appearances are the result of another road by which 
the inflammation invades the bone, namely, by the periosteum. The fur- 
rowed or worm-eaten and softened bone marks the limit of the more complete 
inflammatory act ; beyond that the presence of osteophytes show where less 
inflammation permits formative actions. 



104 DISEASES OF THE JOINTS. 

Third Stage! — The third stage consists in one of two processes, the con- 
solidation into, and tissue-formation of, the granulation mass ; the degen- 
eration and destruction of that material, together with the parts it encloses 
and involves. Neither of these processes takes place alone, without, that is 
to say, some admixture of the other ; nevertheless one, whichever it may 
be, is predominant, and, if it continue, brings the whole joint either to re- 
pair or destruction. 

Separative Processes.— These consist of actions in all respects similar to 
cicatrization. At any stage of the malady the proliferation may stop, the 
inflammation subside ; there then results a short period of entire inaction, 
and after that the granulation mass initiates a metamorphosis into more or 
less perfect fibrous tissue, or more exactly cicatricial tissue. The final re- 
sult depends upon the phase to which the disease had reached before the 
commencement of this curative act ; if only to the first stage, and the carti- 
lages be still entire, or to the second, and the cancellous bone-cavities be 
laid open. 

The process itself is the fibrillation and contraction of the embryonic 
tissue. It commences over a large part, and sends processes or tentacles 
of fibre-tissue farther and farther away, and these form fresh centres from 
which organizing processes start ; a highly irregular network, with elongated 
mesh, is thus spread through the gelatinous mass, each space enclosing 
some of the jelly, which generally rapidly follows the course of the rest ; but 
sometimes remains obstinate ; or may fall into fatty degeneration, 'liquefy, 
and become absorbed, or again may dissolve into pus, forming a localized 
abscess even in the midst of the consolidating tissue. 

As a rule, when the consolidating process has once begun over a cer- 
tain portion of, it spreads through the whole morbid growth, and converts 
it into coarse inflexible fibre-tissue, which uniting the bones, and in its 
cicatricial contraction binding them closely together, forms, if the process 
stop here, false or fibrous anchylosis ; the amount of mobility at the joint 
depending upon the quantity of fresh granulation-tissue which had been 
formed prior to the setting in of the healing process ; to the amount of change 
in the shape of the bone-ends, and to the amount of cicatricial contraction 
which takes place during healing. This contraction, if considerable, brings 
the bones closer and closer together, and at last may bind them so tightly, 
that even if the tissue remain fibrous, but little movement is permitted be- 
tween the bone-ends, probably more or less altered in shape. Also more 
especially if the granulation-tissue have lain very close to the skin, that 
structure will by the same process be drawn inward toward the centre, 
so that after consolidation is complete, the joint will be found smaller than 
its fellow, the skin being tightly stretched over it. If the mouth of an old 
abscess or sinus have existed, this will also be dragged inward, and when 
healed it will present a considerable depression, with hard bottom and edges. 

If the action do not stop at simple fibrillation, the next step is ossifica- 
tion of the structure. This commences always in those layers which lie in 
close contact with the bone, and chiefly those next the edges of the exposed, 
and up to the present time softened, cancellar walls. These walls harden 
again by the deposition of new lime-salts in the pre-existing but altered 
bone ; this depositure does not stop at the old limits, but gradually invades 
the fibres sprouting from those walls in stellate and arborescent forms, until 
the outgrowth 1 from the two bones uniting together prevents all movement, 
and still continuing, causes complete bony union of the joint by a reticular 
osseous cancellar-like structure. These processes are termed respectively cure 
by false and by true anchylosis. 



STRUMOUS SYNOVITIS. 105 

But there is another set of actions which nearly always occurs, some- 
times to the entire exclusion of any reinstating processes, more often 
mingled with such process over smaller or larger spaces, namely degen- 
erative or disintegrating actions. It is evident that such granulation 
tissue as is above described cannot, however persistent, be permanent ; it 
must eventually either move toward tissue-formation, or toward disinte- 
gration ; that which does not become fibre of some sort becomes fatty, puri- 
form or both. In almost every case of strumous synovitis, which advances 
to the stage of cartilage or bone ulceration, or indeed to considerable growth 
of cellular elements, these changes manifest themselves on the surface of the 
newly formed granulations which surround the original cavity, and also in 
various spots in the thickness of the tissue itself. Thus results from the 
former puriform secretion and fatty debris within the cavity ; from the 
latter, localized abscesses in the new parts surrounding that cavity. In ex- 
amining anatomically a joint, the seat of strumous disease for many months, 
the nearly obliterated and irregular cavity is found filled with a flocculent, 
often thin pus, mingled with oil-globules, which has been secreted by the 
granulations, or results from their deliquescence. Such abscesses may 
judiciously be termed intra-articular ; they often he open to the outer air, 
generally by somewhat narrow but not very tortuous channels ; frequently 
also they communicate with one or more of the next sort of abscess. 

Suppuration also frequently occurs in the substance of the new granula- 
tion-tissue ; it is preceded by fatty degeneration at the spot which gives to 
the part a pale, almost greenish, and then when pus begins to form, an 
opalescent or milky look. These " peri-articular abscesses " may, after a 
time, communicate with the fluid in the joint-cavity, they may pass out- 
ward or travel in both directions ; not unfrequently, instead of perforating 
the skin at once, the pus spreads out between that structure and the granu- 
lation, causing a wide separation between them ; and when at last the skin 
gives way, it does so over a wide surface, much of it perishes, and there 
results a rather large ulcer, with blue inverted undermined e,dges, and with 
foul indolent floor,. 

Another class of abscess, that among the muscles in the neighborhood 
of the joint, "adjacent abscess," is far less usual in synovial than in osseous 
joint disease ; more particularly the deeper variety which steals along the 
periosteum is rare in this malady, as also is an elongated abscess running 
up or down^in the substance of the bone itself. We shall encounter them 
in another chapter. 

These more distant abscesses are preceded by formation of fungoid 
granulations, and result from defective plasticity, and subsequent degene- 
ration of that tissue, not from any exuberant vitality of the part. It is, of 
course, to be understood, that neither the curative, formative acts above 
described, nor the degenerative processes just mentioned, occur simultane- 
ously over the whole diseased area, or are always continuous and regular. 
On the contrary, joints that are becoming anchylosed may, in spots among 
the fibrillating tissue, develop abscess, or the intra-articular abscess may 
tend outward, propelled more hastily by the contractile force of the fibril- 
lating tissue itself, and by the pressure thus exerted on the fluid. Thus 
even during the progress of cure by anchylosis, abscess, formed at the time 
or long ago, may point at the skin. Sometimes, on the contrary, the fluid 
parts of the pus become absorbed, leaving somewhere among the meshes 
of an anchylosed joint a dried up mortar-hke material, which may lie qui- 
escent, indefinitely, perhaps altogether, but which, if any fresh source of 
irritation, such as a blow or strain, be superadded, may after many years 



106 DISEASES OP THE JOINTS. 

again liquefy and threaten, or actually develop into abscess. Or again, 
strumous joints which are manifestly in the degenerative and suppurating 
phase will maintain for a time, here and there, a local and restricted ten- 
dency to fibrillation. Yet it is to be remarked that, although sometimes be- 
tween these powers a sort of strife for the upper hand • may take place, the 
one or the other ultimately predominates, and that, even at the point to 
which we have traced this suppurative form of the third stage, recovery, of 
course with a stiffened joint, is still possible. 

If, on the contrary, degenerative actions become predominant, certain 
remarkable events usually occur ; they result from destruction, more or less 
complete, of the ligaments, by the decay of the granulations, which, as we 
have seen (p. 95), permeate their fibres. The joint may even in the first 
stage have become somewhat loosened, but in this third phase, when the 
ligamentous fibres share the fate of the degenerating cell-tissue, the bones 
are so loosely held that the one may be moved in several abnormal direc- 
tions upon the other. Subluxations, in some joints complete dislocations, 
may then take place, generally in the direction of the flexors, 1 because it 
is those muscles which are predominant ; but occasionally in other direc- 
tions, as, for instance, at the knee, though rarely, the tibia may be dis- 
located outward, by overaction of the popliteus. Even now, it is to be 
remarked, healing may occur ; and indeed the luxation itself, the cessation 
of pressure by one joint surface on another, is of itself a cause of ameliora- 
tion. After such event the starting-pains almost invariably cease, at least for 
a time. 

Nevertheless, recovery at this stage, though possible, is not sufficiently 
frequent to render prognosis otherwise than grave. Neither must the con- 
stitutional influence of so severe a drain upon the system be overlooked. 
The patient thus suffering is almost always at the very least strumous, per- 
haps tuberculous, hence phthisis or meningitis are not unusual concomitant 
of joint disease, especially if the latter taint be present ; while the tendency, 
in much more sthenic constitutions, of long-continued suppurations to 
produce lardaceous degeneration of viscera must never be disregarded. 

Thus far the actions in the tissues which form or immediately surround 
the joint have alone been studied, in order that the narrative might remain 
succinct and clear. To complete the history, we must take into account 
certain changes of neighboring parts, which, consecutive in character, are 
not secondary in importance, hardly so in time. Very shortly after the 
tumefaction of strumous synovitis appears, the limb, chiefly in the segment 
above the joint, becomes rapidly attenuated. The first change is in the 
muscles. 2 It has been ascribed to want of use, but there is a cause beyond 
this mere mechanical one. A fractured thigh in splints, its muscles there- 
fore at entire rest, will not suffer such loss of bulk in three months as will 
be produced by a fortnight's persistence of strumous joint disease. The 
mere mechanical theory will therefore not altogether account for the phe- 
nomenon. 

While the muscles thus waste, the joint assumes a fixed posture, natural 
in itself, abnormal only in its persistency, toward the side of flexion. This 
is the case at elbow, wrist, and ankle, while at the shoulder adduction per- 
tains ; at the knee an inward twist of the tibia is usually combined with 
considerable flexion ; at the hip, very complicated positions, to be studied 

1 The hip is left for subsequent consideration. 

2 Of course as the muscles waste, so do the fat-pads which support and separate them 
disappear. 



STRUMOUS SYNOVITIS. 107" 

in a future chapter, are assumed. These postures obtain in nearly every 
case of joint disease, almost with the certainty of an unchangeable law. 1 
There is then in all joint disease a tendency of the flexor muscles to con- 
tract, while the extensors, if not in absolute relaxation, do not, at all events, 
retract sufficiently to annul such action. It is true that flexors are probably 
in all limbs stronger than extensors, but in fact a mere examination will 
show that on the flexor side muscles are rigid, on the opposite side flaccid. 
Our knowledge is as yet insufficient to account for this phenomenon. 

After a time there commence a series of so-called starting-pains, i.e., 
clonic spasms of the muscles. These begin, as I pointed out in 1860, 
simultaneously with, indeed are directly caused by, that fulness of the ves- 
sels immediately under the articular lamella, which is the hypersemia of in- 
flamed cartilage. They act in such wise, that during their continuance the 
joint, which formerly was in a posture of fixed but not abnormal flexion, 
whose ligaments, however, have been greatly weakened or destroyed by 
. the granulating process described at p. 95, becomes now distorted, or, in 
other words, there is extreme flexion, often combined with subluxation. 
In certain joints, as the ankle and elbow, this is less evident than in others. 
At the knee a backward dislocation, and sometimes an outward luxation 
occurs, not unfrequently the latter being due to the action of the popliteus 
muscle. 

The contraction of muscles, continuous and clonic, is at first active, i.e., 
is produced by retraction of the sarkos itself ; but they in a short time, 
thus kept in a state of contraction, undergo fibrous degeneration, the 
true muscular tissue wastes, and is in part replaced by fat, in part by fibre- 
cells. The fibrous envelope is thus thickened, and not only hardens itself 
to the length in which the limb was held by the active contraction, but 
after the manner of all newly formed fibrous tissue, as that of scars, etc., 
goes on retracting, drawing the limb still farther out of position. This 
action, this passive or scar-like retraction, I ventured in my first edition to 
call by the name of " contracture ; " it is, I believe, the same as that which 
Sir James Paget has termed " adaptive atrophy," also a good term, as it 
implies the simultaneous wasting. 2 

The retracted and contractured flexors wasting more or less rapidly, 
thus .degenerate into little else than fibrous cords, but the extensors as a 
rule suffer another form of degeneration ; they are, as we have seen, if not 
absolutely relaxed, at least not contracted, and suffer a fatty degeneration. 
I do not mean here to draw too absolute a line of distinction ; many por- 
tions of the contractured flexors will be found in a state of fatty decay ; and 
some portions of the extensors will be found fibrous, but in the former the 
one, in the latter the other mode of degeneration greatly predominates. 
The atrophy of the limb is not confined to the soft parts, the bone itself 
wastes ; not merely does it become less in circumference, but its medul- 
lary cavity increases ; thus, both on its outer and inner surface, the hard 
cortical part is encroached upon until, as I have seen in amputated limbs, 
and during resections (see case of C. Lobb, Chapter XX.), the shaft of the 
bone is no thicker than a calling-card. Such atrophy is more rapid and 
more complete when the upper joint, rather than the lower, of any long 
bone is affected. Moreover, if ihe whole depth of the epiphysis be dis- 

1 1 should have made this statement even more absolute had I not seen two cases of 
knee-joint disease run their entire course without assuming flexion, and had not Volk- 
mann, in Pitha and Billroth's Chirurgie, referred to like cases. 

2 This term excited some adverse comment at the time, in certain reviews, but has 
since been pretty generally accepted. 



108 DISEASES OF THE JOINTS. 

«ased, that is if the inflammation extends through the joint-end to the 
epiphysal line, the function of that line will be suspended or permanently 
destroyed, according to the violence and power of the inflammatory act 
and to the age of the patient. The bone thus ceases to grow in length at 
the upper or lower end, according to the site of the disease ; hence, after a 
severe synovitis commencing early in life, we nearly always find the dis- 
eased limb shorter than the sound one. But this has its exceptions ; for 
if inflammation have not been severe, or, being severe, have not spread in 
all its intensity to the epiphysal line, the action at that line may have been 
insufficient to check, but, on the other hand, will have stimulated growth, 
and occasionally, as a result of synovitis, actual increase of length will be 
produced. 1 It occasionally happens, more frequently at the hip than at 
other joints, that complete separation of the epiphysis (diastasis) takes 
place. In Fig. 3 is an instance of this occurrence at the upper end of the 
tibia : the malady was osteitis ; but much the same form is presented if 
such displacement arise in a late stage of synovial disease. 

Symptoms. — As the task now before me is to give not merely the local 
signs of a synovitis but the diagnosis of a scrofulous malady, it is necessary 
to take into account the appearances, which may lead to the conclusion 
that a patient is the subject of struma. I believe, as I pointed out many 
years ago, that a certain confusion has existed on this subject, and that 
some of the appearances produced by certain diseases of admitted strumous 
origin, such as phthisis, tabes mesenterica, etc., have been described as 
diagnostic signs of struma itself. 

Struma is not a disease, but a condition of bad nutrition, which marks 
itself in the aspect in one of two ways, either by an excessive delicacy, 
thinness and sharp-cut outline of connective tissues, with clearness and 
transparency of skin ; or by a gross, coarse, ill-concocted condition of the 
same parts, which therefore are large, blunt-edged, ill-defined, and coarse. 

The former of these types is marked by excessive refinement and de- 
fined in the modelling of the features ; the cartilages of the nose are clearly 
outlined ; the eyelids also well carved and defined, frequently fringed with 
long curling lashes. The conjunctiva' and sclerotic are so thin, that the 
dark pigment of the inner chambers reflects through them a bluish tinge. 
The pupil is often large and somewhat sluggish, even though the iris be of 
a light color." The skin is clear and ash-colored, especially about the 
upper lip and corners of the mouth, and in the very cool-toned shadows 
looks translucent ; indeed it is actually translucent, for in certain parts, as 
the temple, eyelids, across the lower jaw, near the angles and the side of 
the nose, veins are easily seen through it ; the redness of the lips is bril- 
liant and luscious. The whole aspect is that of refined, almost ethereal 
beauty. ■< 

The other type is generally marked by ugliness of the coarsest descrip- 
tion. The head is large and angular or " nubbly," is bigger behind than in 
front ; the great red ears, shapeless and puffy, stand out asplay. The jaws 
are prominent, the lips thick and ill-defined, generally sway apart ; the 
nose swollen, and its cartilages ill-defined ; the hair coarse and dull, either 
dark or gravel-colored ; the eyelids, thick and clumsy, are often bordered 
with red even when not inflamed, the lash ill-developed and scattered ; the 
conjunctiva opaque and muddy ; the complexion dull and unclean-looking ; 

1 See some cases by Mr. S. Jones, and cases related at p. 235 et seq. 

2 Hufeland (Ueber die Natur der Skrofelkrankheit) describes this peculiarity to 
commencing mesenteric disease ; but I think without sufficient grounds. 



STRUMOUS SYNOVITIS. 



109 



the coarse, unctuary skin is marked with large orifices of sebaceous ducts. 
The figure is usually ungainly ; the limbs unwieldly ; the joints, hands, and 
feet large ; the belly prominent. 

These descriptions are given, each of them, from the extreme limits of 
their domain ; they will serve to mark what I wish to point out, namely, 
that the state termed struma is one which is closely connected with, per- 
haps consists of defective interstitial nutrition of all the connective tissues ; 
in the one type apparently by difficulty of assimilation, whence the delicate, 
but half-starved refinement of cartilages, bones, fasciae, and of the features 
formed by them ; in the other type by large, probably excessive, assimila- 
tion and difficulty of absorption — and we know how much the lymphatic 
system is involved — hence the sodden, shapeless, almost swollen-looking 
bones, features, etc. If, therefore, some nutritive defect of connective 
tissue lies at the root or near the root of scrofula, we cannot but find that 
an inflammation of such tissue, however set up, must bear and reflect the 
peculiar character of this evil ; in a strumous subject inflammations of 
connective tissue will be strumous. The 
more characteristic therefore be the marks 
of diathesis, the easier will it be to diag- 
nose the specific character of any inflam- 
mation. 

Strumous synovitis is far more frequent 
in children and .young people than in 
adults. In them it affects the larger in 
preference to the smaller joints, is partic- 
ularly prone to attack the knee and the 
hip ; ' its next most frequent seat is the 
ankle and elbow, then the shoulder, and 
the joints of the tarsus and carpus. 2 "When 
it attacks adults it affects the elbow, carpus 
and tarsus in preference to large joints. 

Fiest Stage. — Chronic synovitis may 
begin in different ways — either as the 
obstinate residuum of an acute attack 
brought on by injury, overfatigue, expos- 
ure, or other such cause ; and here the 
history of origin may assist the diagnosis, 
for a relic of rheumatic fever will hardly 
be strumous. Or the malady may com- 
mence with some obscure pain or sense of 
weakness, producing a certain stiffness and 
lameness of the limb ; and this condition 
may persist for a week or more before any 
swelling is perceptible, at least to the untrained perceptions of nurse or 
mother. 3 Or, lastly, the first sign of disease may be an utterly painless en- 
largement, with which the patient moves about and uses the limb as usual, 
of which he is even unconscious until it is noticed by some attendant. This 

1 As a special chapter will be devoted to hip-joint disease, I shall say nothing con- 
cerning its peculiarities in the present place. 

2 In most cases of tarsal and carpal disease, it is not possible to diagnose synovitis 
from osteitis. 

. 3 The gentle commencement of the disease alarms so little, that the limb is seldom 
immediately subjected to surgical examination hence ; the time when swelling com- 
menced is in most cases uncertain. 




110 



DISEASES OP THE JOINTS. 



last is in my experience the manner in which the worst and most obstinate 
cases commence ; it occurs only in those constitutions strongly marked by 
strumous taint. Cases thus beginning assume the form which Sir B. Brodie 
called a morbid change of the synovial membrane, and which he considered 
as a semi-malignant form of disease. 

When the first and second mode of commencement obtains, the swell- 
ing, will at first have much the form of the synovial membrane ; but this 
condition is very short, and corresponds only to the few days when there 
is some increase of fluid in the joint, and very little new tissue in and 
around it ; in this state the swelling fluctuates slightly. Some time after 
the disease has begun in this manner, the joint may actually decrease a 
little in size, and the tumefaction left will be no longer fluctuating, nor so 
soft as previous to the diminution. Instead of conveying to the practised 
finger the sensation of confined fluid, it gives that of a soft solid ; the de- 
crease, under these circumstances, is 
of no good omen ; the fluid may have 
almost disappeared, but there has been, 
instead, formation of gelatinous tissue. 
From this time the condition will be 
the same, whatever may have been the 
beginning of the disease ; the joint 
will continue more or less gradually to 
swell, the shape of the tumor becoming 
very different to that of an acute syno- 
vitis ; its chief characteristic is that of 
shapelessness ; its form is not affected 
by the position of tendons or of liga- 
ments ; but includes them all in its 
vague boundaries. 

The sensation which the tumefac- 
tion conveys to the hand is soft and 
boggy, such as, to the educated fin- 
ger, may give the idea of fluctuation. 
Many parts of the swelling are softer, 
and some parts a little harder, than 
the general mass. These soft spots 
are not more truly fluctuating than the 
others ; the increase in softness is all 
that can be observed about them. The 
harder parts seem to He in the mass, to have no defined boundaries, and 
cannot be separated, lifted up, or seized by the fingers. This swelling con- 
ceals and covers the bones, which can only be felt through it ; their promi- 
nences and depressions muffled and rendered indistinct by the doughy 
thickening of soft parts around. It is at this stage that the distinction 
between a strumous synovitis and ostitis can without difficulty be made in 
all but very deep or small joints, as the hip, or the tarsal and carpal articu- 
lations. The distinguishing mark is chiefly the fact of a soft sweUing cov- 
ering, as above described, bones which are not enlarged ; while in ostitis, 
although some swelling of soft parts can be detected, it is much less than 
in synovitis, and the increase of size, by making rather firm pressure be- 
tween the finger and thumb at one and the other side of the joint, will be 
found to be clearly bony. If the plates illustrating Chapter "VII. be com- 
pared with those now given, the distinction will be obvious to the eye. ' Of 
course it is only in very typical cases that visual diagnosis can be made ; 




Fig. 11. — Strumous synovitis of knee. 



STRUMOUS SYNOVITIS. 



Ill 



"but the principle is the same to the touch and to the sight : in the first 
stage of strumous synovitis the swelling is situated in the soft parts — is it- 
self soft ; bony enlargement cannot be made out, but, on the contrary, the 
soft swelling beneath the shin covers and conceals the bones. In osteitis 
the enlargement, although the 
soft parts may be somewhat 
thickened, is osseous,' and one 
or the other bone forming the 
joint, even one or another part 
of the bone (as inner or outer 
femoral condyle) may often be 
felt, even seen to be enlarged. 

The enlargement, although 
described as shapeless, in con- 
tradistinction to that of acute 
synovitis and to osteitis, is never- 
theless not without form ; in- 
deed, every joint has its pecu- 
liarity, which some experience 
will teach better than mere de- 
scription. The engravings may 
aid, however, in directing obser- 
vation aright. The shoulder thus 
affected is especially, and par 
excellence, shapeless, a mere 
rounded swelling at the top of 
the arm. The elbow presents in 
front two conical enlargements, 
each with its base toward the 

joint, each diminishing as it is traced toward the upper and forearm re- 
spectively. The forearm tumefaction is chiefly on the radial side, at the 
back above the olecranon, and on each side of the triceps tendon. The 
swelling of the wrist is chiefly at the back, and although it may encroach 

upward and downward, it has its long axis across 
the limb, and in looking at it in a good light fall- 
ing lengthwise from the hand upward, a line of 
shadow above the radius, a high light and reflec- 
tion over the situation of the joint run both in 
that transverse direction. The peculiar round 
form of the knee, and in synovitis the absence of 
any predominant swelling on either one side or 
the other, have already been noted. When the 
ankle-joint is diseased there is often some diffi- 
culty in the diagnosis. It is to be distinguished 
from thecal enlargement by the direction of the 
swelling, which is transverse to the axis of the 
limb, as also by the fact that in joint disease the 
whole circumference, behind the malleolus as 
well as in front, is enlarged. In swelling from dropsy or suppuration of 
the sheaths the tumefaction is in a direction parallel with the limb's axis, 
and it is very rare that the posterior and anterior sheaths are both affected. 
At p. 130, Fig. 15, an ankle is represented as seen from behind ; the dis- 




Fio. 13. — Strumous synovitis of the elbow. 




Strumous synovitis of 



1 For description of this form of swelling, see chapter on Strumous Ostitis. 



112 DISEASES OF THE JOINTS. 

ease had advanced to suppuration on the inner side ; hence, that part is 
rather more protuberant. 

As the soft swelling increases, the joint becomes by degrees whiter than 
normal. This peculiarity is the more marked the more strumous be the 
case, so that we may roughly conclude, from the color of the skin, on the 
sort of granulation forming beneath it. The symptom was that which 
caused Wiseman, in 1734, to apply to this disease the name of white swell- 
ing, a name which has fallen into disuse in England, though its synonyms, 
tumeur blanche, tumor albus, etc., are, or have been till quite recently, 
retained on the Continent. When the case is far advanced, this whiteness 
is very striking ; and in some cases where the granulating, the first stage 
of the disease, is prolonged, and the swelling therefore very considerable, 
the skin becomes stretched and polished ; beneath it may be seen mean- 
dering a few veins, which, being flattened out by the growth between them 
and the skin, look broader and bigger than the norm. 1 In estimating the 
amount of swelling by the eye alone, the surgeon must take care not to be 
misled by the atrophy of the muscles which accompanies this disease. Of 
course such shrinking of the limb is most deceptive if the diseased joint be 
in its middle, as the elbow or knee. I have often heard tumefaction spoken 
of as enormous when accurate measurement has shown it to be slight. Heat 
of a joint thus affected is only present quite at the commencement of cer- 
tain cases, when the condition might be better named subacute than chronic ; 
it may also be a fugitive symptom, occurring at night in a further stage of 
the malady. I have thought at times that a joint in the early stage of this 
disease felt even colder than the norm, but observations with the thermom- 
eter have never verified this notion. 

The pain accompanying this form of disease is very variable. In some 
cases all the first stage is, unless the joint be much moved and worried, all 
but painless. It is true that a child thus affected will often wake suddenly 
from sleep and cry for some time, 2 an act which is perhaps often caused by 
an unconscious movement of the limb, producing a stab of pain. In hos- 
pital, as in private practice, children with greatly swollen joints are fre- 
quently seen with countenances that bear no mark of suffering : now any 
continuous pain, or any frequently reiterated pain soon leaves its mark on 
the facial expression. Among older persons, from whom definite complaint 
may be elicited, pain while the limb is at rest is not a prominent symptom. 
A dull aching, worse at night, or a gnawing, a sense of distention, are men- 
tioned, but not with any marked emphasis. In one case that occurred to 
me in 1858, a feeling of intense cold in the joint was the most prominent 
sensation. I cannot attach any value, diagnostic or prognostic, to the sort 
or amount of pain complained of at this period of the disease. 

Besides pain when the joint is undisturbed, we must consider tender- 
ness, i.e., pain produced by pressure. Every joint affected with synovitis 
has its own particular spot of tenderness, which in some joints is also the 
spot to which ordinary pain and the shock of starting-pains are chiefly re- 

1 This enlargement of veins is a constant appearance in all cases when a more or 
less deep-seated tumefaction grows with some rapidity toward the skin ; it occurs in 
encephaloid, in many sarcomata, in rapid suppuration of a joint-membrane. It is not, 
therefore, pathognomonic of any form of disease, but only of the locality of growth ; 
but the quicker the growth, the more marked and numerous are the veins ; hence, while 
in encephaloid a whole meshwork of enlarged venous radicles net out the surface, in 
strumous synovitis only a fe.w not greatly interlaced markings appear beneath the 
skin. 

2 I am not here speaking of the so-called atarting-pains, to be hereafter described. 



STRUMOUS SYNOVITIS. 113 

ferred. At the shoulder this spot is in front, just below the acromion, in 
the elbow, the back where the radius is jointed to the humerus. At the 
wrist it is at the back, outside the extensor indicis tendon. At the hip, if 
there be pain at the commencement of the disease, it is situated at the in- 
side of the thigh, just behind the origin of the gracilis muscle; afterward 
it shifts and fixes itself behind the great trochanter.' At the knee it is sit- 
uated on the inner condyle, just inside the edge of the patella. At the ankle 
about half an inch in front of the outer malleolus. 

These spots of chief tenderness are so constant that their existence may 
be received as an absolute rule, although exceptions do now and then occur. 
I have been quite unable to find, by the most careful investigation, any cause 
for this localization of tenderness ; we must at present be content to accept 
the simple fact. 

This description applies to the larger joints ; compound joints formed 
of small bones (carpus and tarsus) often yield few signs by which we may 
certainly distinguish synovial from osseous struma, since the one very 
quickly succeeds the other. 2 The malady at the wrist Usually assumes the 
form shown in Fig. 36, which was originally synovial. This formative phase 
of the disease lasts in some cases a very considerable time without the occur- 
rence of any other morbid change, and then frequently comes a period of pas- 
sivity ; the swelling neither increases nor decreases, pain is not complained 
of, the patient ceases to lose, but does not gain much health, although sleep- 
ing well, eating fairly, but often unable to take exercise he continues some- 
what pale and weakly. The joint is not painful, though it probably, if 
permitted, assumes a more exaggerated position, immediately to be de- 
scribed ; it is not hot nor tender. There appears no inflammatory change, 
either progressive or plastic, the especial spots of tenderness give some 
slight response to pressure. By far the larger number of cases have this 
period of stasis, lasting in some but a short, in others a very long time. 
The wards of some hospitals are cumbered with splintered children, getting 
neither better nor worse. After this period comes on a phase either of 
progress or regress. 

This latter invasion of cartilages and of bones, degeneration and suppu- 
ration, is sometimes very rapid, and it is the rapidity pf such events which 
appears to me to lead some eminent men to doubt the possibility or even 
desirability of making any distinction between strumous maladies com- 
mencing in the hard or in the soft parts of the joint. 3 But these cases are 
by no means the most usual ; and even were they more common than they 
are, such occurrence cannot be used as an argument against accepting a 
frequently clearly marked distinction, which must greatly add to the preci- 
sion of prognosis, and often to the great advantage of treatment. 

However — and this is the chief reason of my mentioning it here — a con- 
siderable variety in the rapidity of different cases leads to some difference 
in the precise pathological moment at which those important manifestations, 
fixed posture, abnormal mobility and subluxation, occur. Some account 
was given of these processes in the former division, and confession made 
of my inability to find reason for the perverted reflex action producing 
them. 



1 For further account, see chapter on Hip- Joint Disease. 

3 Hydarthrus of the carpal synovial membrane (a rare disease, which I have twice 
seen) gives a proximate idea of what a fungating disease remaining purely synovial 
would be like. 

3 See Volkmann in Billroth' s and Pitha's Chirurgie, Bd. ii., p. 521 ; Holmes's Sur- 
gical Diseases of Childhood, p. 435. 
ft 



114 DISEASES OP THE JOINTS. 

The fixed posture, always to the side of flexion, generally commences 
during the first, but becomes more marked during the second stage of the 
disease ; in some joints, as the ankle and elbow, pure flexion obtains : at 
the shoulder adduction, probably the expression of flexion at this joint. At 
other places, as at the hip, flexion is complicated by several additional pos- 
tures, which will be studied in a separate chapter. At the knee flexion so 
greatly predominates that a certain inward twist of the tibia, which gener- 
ally, if not always, coexists, is generally overlooked. While the postures 
are thus becoming persistent, the limb shrivels very rapidly. On examining 
the state of muscles, the extensors are found to be flaccid, while the flexors 
are more contracted, though not firmly so ; any attempt to straighten the 
joint, or even a belief that such an attempt is about to be made, causes 
these latter muscles to become at once rigid. 

Abnormal Mobility. — The term implies that the bones composing the 
joint can be moved by the surgeon's hand in directions impossible to a nor- 
mal articulation. At the knee the tibia may be made to glide laterally on 
the femur, or may be rotated, or may, while the knee remains straight, he 
moved from side to side. At the elbow the ulna may sometimes be made 
thus to move laterally, or when the joint is bent at a right angle the ra- 
dius may be moved up and down. At the ankle a backward and forward 
movement may be produced. As such conditions have been shown to arise 
from breaking down or absorption of the ligaments, this symptom is a sign 
of the intensity of the disease, and of its destructive invasion of tissues, ne- 
cessary to the joint as a centre of motion. It must, however, be said that 
any considerable false mobility is rare in this stage of the disease ; still 
more infrequent is subluxation, save at the knee a slight displacement of 
the tibia backward, which is not uncommon even in this first phase of fun- 
gating synovitis. 

The Second Stage is ushered in by certain peculiar symptoms called 
" starting-pains," being a combination of pain and of muscular spasm, but 
which of the two has the priority in point of time and causation is impossible 
to say. The pain is always referred to the special points of tenderness already 
(p. 110), mentioned, although it radiates up the limb. The startings rarely 
occur in the daytime while the patient is awake ; but at night, just as he is 
falling to sleep, rouse him with a sudden stab of pain and a sense of horror ; 
indeed, many regard these attacks with such dread that they keep them- 
selves awake as long as possible in order to avoid, or at least postpone, 
their advent. When slight, they do not visibly move the limb ; in their 
more severe form, as I have frequently seen, the limb, with even the splint 
upon it, jumps a little way from the bed. Young patients frequently cry out 
loudly, yet may, even before the nurse can reach them, fall asleep again ; 
others refuse to sleep, and beg not to be left alone. The advent of these 
pains is most important, as marking the particular pathological phase of 
the disease ; while they are severe, and increasing ulceration of cartilage is 
imminent, 1 or has already commenced, they are indeed directly caused by 
the hyperaemia immediately under the articular lamella, which always ac- 
companies that process. This fact, which I first pointed out twenty years 
ago, has been generally accepted as the correct interpretation, leading to a 
clear comprehension of the actual occurrences taking place in any given 
case of joint disease. These pains, which are remittent and transitory, are 
generally coincident with a certain form of constant pain, usually described 



1 It will be pointed out in another chapter that these, the more severe form of pains, 
are earlier in strumous osteitis than in synovitis. 



STRUMOUS SYNOVITIS. 115 

by the patient as " gnawing " or as " soreness of the bone ; " in some cases 
a sense of distention, a bursting pain is mentioned. 

When these sensations, the more or less constant and the irregular, have 
lasted a certain time, longer if they have been slight, shorter if severe, 
another symptom is added, viz., tenderness on pressing the joint-surfaces 
together. The origin of this symptom, although extremely obscure, I be- 
lieve myself to have detected. By questioning minutely for years every 
patient that came in my way, by observing the species and succession of 
different sensations, and examining, when possible, the joints of those 
whose symptoms had been thus noted, I have come to the conclusion that 
this tenderness indicates that the articular lamella has given way over a 
larger or smaller extent, and that the cancelli are laid bare to the joint. 
The actual sequence of events can in most instances be traced, the starting- 
pain coming on first — two or three weeks, or even more, before the tender- 
ness supervenes. Having examined a very large number of joints, in all 
sorts and conditions of disease, and having, wherever it was possible, com- 
pared the symptoms with the morbid anatomy, I can affirm that I have never 
heard complaint of this peculiar joint-tenderness without finding the artic- 
ular lamella broken through. I have found the lamella given way in cas,es 
where there had been no joint-tenderness ; but then the breaches of conti- 
nuity had been either very small, or situated in some part, where, in the 
position of the limb, it could not be pressed upon by the other bone of the 
joint. In seeking this symptom, extreme care must be used lest the limb 
be moved ; motion, either flexion or extension, of a diseased joint often 
•causes pain which is not that being looked for. Again, we must not let 
the patient involuntarily deceive us ; many persons who have long been ill 
with articular disease habitually complain when the joint is touched, whether 
they be hurt or not, being moved thereto by fear that something to give 
pain is about to be done. 

Grating or bony crepitation in the articulation is a symptom which, 
when it occurs, proves an ulceration of cartilages throughout, probably a 
considerable extent of both bones ; but the absence of this grating by no 
means proves that the cartilages are sound, for granulation from the bone 
may be so luxuriant as to prevent the two osseous surfaces coming in con- 
tact. It not unfrequently happens that, during some part of the progress 
■of the case, the bones will grate, and that afterward they will altogether cease 
to do so. The reason of such cessation is, after what has just been said, 
perfectly evident. 

In this series the symptoms usually succeed each other in case after case 
with an almost monotonous iteration, yet sometimes variations occur, pro- 
duced either by great nervous irritability or more generally by extreme 
instability of the granulation-tissue, causing the third stage, that of de- 
generation, to supervene even before the second is well established, thus 
mixing up the symptoms of the one with those of the other. 

Generally during this second phase, especially if it continue a consider- 
able time, the starting-pains are followed by further effects. One of these 
is more complete and permanent shortening of muscles — contraction is suc- 
ceeded by contracture. This change takes place very gradually ; hence, it 
is impossible to mark exactly the time of its commencement. A muscle 
slightly contractured feels but little different from a normal one ; but when 
the process has somewhat advanced the stringy feel of fibrous degeneration 
can plainly be distinguished. These, shortening and the spasm combined, 
acting on a somewhat loosened joint, may even now begin to produce sub- 
luxation, but this condition is more fully developed in the later phase. 



116 DISEASES OF THE JOINTS. 

The Third Stage embraces one of two actions, either progress toward 
cure, or toward destruction of the joint by degeneration, suppuration, or 
caries. 

The former of these may occur at _any phase of the disease,- and the 
earlier the better will be the result. The signs of such beneficial change 
will be, firstly, improvement in the general health, more marked if it have 
previously considerably suffered ; the improved appetite, increasing strength, 
cessation of night-sweats, of starting-pains, as well as a more even thermome- 
ter at a lower grade, indicate a better condition of system. Locally, there 
ensues a decrease of swelling, together with greater hardness and resiliency 
of the enlargement ; improved coloration of the skin over the joint, while 
the meandering veins, if there have been any, and any slight abnormal mo- 
bility, disappear. The shape of the bones gradually becomes more per- 
ceptible, and they are not so far from the surface. If when these actions 
set in the first stage" have not been passed, the limb will recover with merely 
an amount of joint stiffness (the result of thickening), which in time may 
be eliminated. If the second stage have been reached, a more severe lame- 
ness, greatly to be alleviated, but perhaps never to be quite overcome, will be 
left behind. If the destructive processes of the third stage have proceeded 
pretty far, a joint partially stiffened by false or quite stiffened by true an- 
chylosis is the best result attainable. 

The hardening of the swelling and its diminution is a more or less rapid 
or slow process, according to the energy of the formative acts which the 
hitherto all but unchanging granulation-tissue has assumed. As it goes on, 
the skin becomes more and more drawn inward to the bones, and at length, 
if considerable swelling have been present, becomes stretched over them 
tightly — cicatricial contraction — the joint loses not only abnormal, but also 
normal mobility to a very great extent ; and when the process is complete, 
the new fibrous tissue, fully formed from the granulations, binds the bones 
firmly together, often so rigidly that only a little doubtful movement can be 
obtained ; this is false anchylosis. (See Chapter XIX.) 

True anchylosis, viz., the ossification of .the fibrous tissue, frequently 
follows upon the false with very considerable rapidity, but is in other cases 
a slower process. It announces its commencement by no distinct symp- 
tom ; greatly increased, and at last complete immobility indicates a little 
later what actions are or have been taking place. 

A great many joints thus diseased do not go through this stage of cica- 
trization regularly and pari passu over the whole area of morbid action, cer- 
tain parts in some cases will solidify, others degenerate and suppurate. At 
certain times, according to fluctuations of systemic health and vigor, the 
one or the other action will predominate. Yet any attempt at this mode of 
healing, sufficiently marked to be detected, is of encouraging augury, and 
should be fostered, as it has great tendency *to become more widely propa- 
gated among the tissues. Yet, only too frequently, the contrary actions 
prevail, sometimes mingled with fitful attempts at healing ; and usually 
slowly, at other times very rapidly, all the new growths and the parts in- 
volved in it appearing to break down almost at once into degeneration and 
abscess. The general and local symptoms will vary accordingly. The ad- 
vent or approach of this condition may be suspected if the thermometer, 
fluctuating considerably, fall during the daytime below 98°, while 'a sud- 
den sharp and persistent rise marks the commencement of rapid disinte- 
gration. 

If also the tumor of the joint do not diminish, but continue to increase 
without sign of active inflammation ; if the articulation become more loose 



STRUMOUS SYNOVITIS. 



117 



in abnormal directions, we may feel assured that degeneration and suppu- 
ration will probably Occur ; if the skin become whiter and more polished 
and lose its mobility, while the tumor continues to enlarge ; if the soften- 
ing mass feel as though it were immediately beneath the surface, we may 
conclude that those retrograde actions are imminent, or perhaps have actu- 
ally begun. 

The tumefaction usually increases, and if this increase be general it 
gives to the whole swelling a still more rounded appearance ; the skin over 
it is either dry and furfuraceous, or if the enlargement be sufficient to pro- 
duce tension, smooth and polished ; under these latter circumstances, if con- 
siderable pain, of a dull aching character, be experienced, and if a certain 
pyrexia, well marked by the up and down movements of the thermometer, 
be verified, acute intra-articular abscess will form ; it is not a very usual 
result of fungous synovitis. Frequently it is not the whole inner wall of 
the new tissue which thus degenerates, but one or more spots in its thick- 
ness ; such peri-articular abscesses may exist a certain time without making 
their presence known by any 
distinctive symptom ; unless 
they be of rapid formation or 
near the surface, they may 
even open into the central 
cavity without exciting more 
than a suspicion of their pres- 
ence. After a time, however, 
they approach the skin, and 
then a local enlargement, a 
rounded protrusion of a part 
of the intumescence, will ap- 
pear, and over this, unless it 
be incised, the skin will red- 
den, frequently over a large 
surface, and break, giving exit 
generally to only a small quan- 
tity of ill-concocted, flocculent 
pus. The opening thus formed 
may rapidly degenerate into a 
sinus, from the mouth of which 
sprout large, flabby, and gen- 
erally pale or greenish granu- 
lations ; or if the pus have 
previously undermined a wide 
extent of skin, a large flat ul- 
cer, around which the skin lies 

loose on the subjacent tissue, is left. There is some difference in the be- 
havior of these abscesses, according as they are more or less deep or super- 
ficial ; the latter may open anywhere about the joint. The former generally 
make their way first into the central cavity, and then, like the intra-articu- 
lar abscesses, open outward in certain spots which are more definite for the 
deeper than for the superficial articulations — as for the shoulder and hip — 
the choice locality in the former instance is just inside the biceps, about 
half an inch from'the edge of the great pectoral muscle, for the latter are 
several spots described in another chapter. Adjacent abscess, either inter- 
muscular or periosteal, though unusual in this form of disease, should 
nevertheless be looked for. They produce, the former, certain lines of ful- 




PiQ. 14.— Pathological dislocation of the tibia outward. 



118 DISEASES OP THE JOINTS. 

ness rather than of hardness, running from the affected joint upward, very 
rarely downward ; the latter a sense as of increase in size of the bone. 
Their mode of detection is more fully described elsewhere. 

While the granulation-tissue thus softens, the ligamentous fibres en- 
closed and permeated by them share . a like fate, and subluxation or com- 
plete dislocation is a common event at this stage, especially at the hip, 
knee, shoulder, and upper radial articulation ; that at the hip is of all 
complete pathological luxations the most common. The radius is often 
dragged upward by the action of the biceps, but the displacement is rarely 
entire. The tibia is generally drawn backward on the condyles, so that 
a marked deformation of the joint results, namely, the lower end of 
the femur makes prominence in the patellar region ; below it is a marked 
depression, while behind, the lower part of the popliteal space projects 
abnormally backward. Occasionally, too, at this joint, a very singular dis- 
placement outward of the tibia is too well marked to require any descrip- 
tion. The outer condyle of the femur rests on the inner articular facet of 
the tibia, while the inner condyle has lost its opposing bone. The shoulder, 
rarely the seat of strumous synovitis, tends, when thus affected, to dislo- 
cation toward the axilla. 

Sometimes, whether luxation occur or no, the patient may fall into a 
state of considerable weakness, when the degenerations above described 
become more rapid, are not confined to spots here «nd there, but take 
place almost simultaneously throughout. Thus the whole mass may more 
or less rapidly suppurate or suffer fatty degeneration ; fluctuation over the 
whole space will be evident, and when the pus is evacuated, it brings with 
it parts of the fibrous tissue which have been included in the granulations, 
and also bony detritus from the cancellar walls which have been similarly 
involved. Such local changes are accompanied by considerable general dis- 
turbance, inedia, emaciation, and night-sweats, together with very strongly 
marked thermometric derangements, the temperature being nearly or even 
below normal in the morning, and rising to 102° or more in the evening. 
Surgery usually spares to the patient these ultimate sufferings of joint 
disease. 

Omitting this last described phase, it must be noted that from the 
former condition, i.e., from peri-articular and intra-articular abscess, patients- 
may yet recover, of course with anchylosis. Such favorable course is 
marked by decreased violence of the starting and other pains, and by 
diminution of the swelling, which becoming harder seems to press the pus 
out of the abscess cavities, and the discharge decreases in amount, altering 
its characters from a flocculent ichor-like fluid to good creamy pus ; as 
time goes on, this may afterward again become thinner, but then resem- 
bles thin mucus or serum. The granulations become of a healthier 
character, they protrude less and less, come to lie on a level- with the skin, 
then are as it were sucked in as a snail into its shell, sit below the level of 
the surrounding surface, and when healed, form what is called a depressed 
cicatrix. This retraction of the sinus granulations is merely a part of the 
general cicatricial contraction that is taking place, whereby the tissues con- 
solidate, and may become even abnormally hard. Indeed in the cases 
which originally were marked by very considerable puffy swelling, the 
tissue-contraction is so great that the joint, when fully healed^ is smaller than 
the norm, and the skin seems drawn close to and between the bones. A 
limb which has gone through these processes of disease and repair exhibits 
shrunken and feeble muscles, a joint formed by small and more or less 
misshapen bone-ends, to which the skin, much changed, smooth and shiny,. 



STRUMOUS SYNOVITIS. 119 

is closely attached ; while at varying distances from the joint, depressed, 
reddened cicatrices mark themselves very plainly. 

Treatment — General. — It perhaps hardly comes -within the scope of the 
present work, nor is it otherwise advisable, to enter into any long treatise 
on the treatment of struma. Yet is evident that, in dealing with a disease 
■which takes root in a certain state of system, all attempts at cure would be 
fruitless, unless some means were employed to alleviate the constitutional 
evil. In the first place, all hygienic measures must be taken — close dwell- 
ing-rooms are to be ventilated ;. light admitted to the fullest possible ex- 
tent ; unhealthy diet changed, and cleanliness inculcated. Upon these plain 
rules of living we need not linger. 

Two different aspects of strumous disease were described at page 106, 
with some care, because they ought to indicate two different forms of treat- 
ment. The distinctions, although frequently as strongly marked as there 
indicated, do not always diverge to that extreme degree ; therefore, the 
treatment to be 1 described for each will not always be so opposed but that 
their principles may be somewhat intermingled. 

That form of scrofulous disease, which is marked by thick unwieldy 
connective tissues, is in adults very generally, in younger persons invaria- 
bly, combined with a sluggish intestinal canal, accompanied usually in the 
latter instance with thread-worm. The whole tube is lined by a thick 
viscid mucus, which does not stimulate the peristaltic actions, nor permit 
either food or remedies to come in contact with its mucous coat. This 
matter must be purged away, and the best means for the purpose is a 
powder of calomel and jalap or calomel and rhubarb. In another chapter 
(see Chapter XI. ) the action of this remedy in articular disease is compared 
with its effects in strumous ophthalmia. We can, in this latter malady, 
actually see the morbid symptoms decline as soon as the intestines are clear. 
In strumous synovitis the benefit is not less certain, though it may be less 
plainly perceptible. In one or two cases of commencing strumous joint dis- 
ease, the exhibition of this remedy, combined with suitable local means, has 
checked the complaint. It not unfrequently happens, that after the medi- 
cine has had its due effect, the complexion will resume its muddy hue, and 
the eyelids become again red ; the dose should then be repeated ; but 
proper dietetic and medicinal measures will prevent the necessity of re- 
curring to the purge more than once or twice throughout the whole com- 
plaint. Small alterative doses of mercury may, however, be given for a 
day or two with advantage. This medicine is not in these cases to be 
pushed to any point near affecting the gums ; it is simply to correct the 
secretions, and is the more beneficial if it produce rather free action of the 
bowels. For this purpose, it may be advantageously combined with qui- 
nine ; as, for instance, two grains of the gray powder with one of quinine, 
night and morning for two or three days, and then the latter may be ad- 
ministered alone twice or thrice in the twenty -four hours. 

Iodide of potassium is especially indicated ; it may be given in some 
bitter infusion. I have been in the habit of using the following formula, 
a little altered from one of Lugol's, the action of which is quicker than the 
iodide alone : 

3 . Iodide of potassium 1 drachm. 

Tincturse iodi ni viij. 

Infusion of calumba 1 pt. 

It is singular that the addition of the pure element detracts from the 
metallic tast e of the compourirl. and r enrlpra ii less lasting. The formula 



120 DISEASES OP THE JOINTS. 

appears, in some of the reported cases, as the Mistura Potassii Iodidi 
Composita. 

Quinine, mineral acids, and bitters, are the tonics most beneficial in 
this form of the disease. Iron is far less valuable, and cod-liver oil very 
frequently disagrees, besides aiding the tendency to clogging of the intes- 
tines and sluggishness of the liver. 

The form of struma, which is distinguished for the fine delicate forma- 
tion of the connective tissues, is to be managed on a different plan. Purges 
and mercury in any form must be avoided ; the inaction of the intestinal 
canal is to be combated by mild vegetable aperients ; rhubarb given in pill 
immediately before or with the last meal at night is an excellent plan, and 
anything hie a violent or irritating evacuant does harm. Iodide of potass 
alone in the most typical cases of this sort of struma is not beneficial ; the 
whole class of alteratives are not needed. 

On the other hand, tonics are extremely valuable. Cod-liver oil is 
especially indicated, as we desire increase of nutriment ; in these cases it 
very seldom indeed disagrees. Quinine, if the appetite fail, is useful ; but 
iron is to be much more highly prized. I have found great benefit from 
iodide of iron, but have no esteem for the usual preparation, the syrup ; I 
give it in a nascent form, prescribing it in two mixtures, two or three grains 
of iodide of potass, and five or eight minims of tincture of iodine in the 
one, five grains of citrate of iron and ammonia in the other, a dose from 
each is mixed just before taking ; in fact, I esteem steel and the oil as the 
best medicinal agents : where the latter has been found unsuitable, sar- 
saparilla may be advantageously administered. Malt liquors, milk, if pos- 
sible cream, should be included in the diet. It may be pointed out that in 
these cases the stomach is usually capable of managing only a little food at 
a time ; therefore, the meals should be small and frequent. I have often 
found that these patients are very languid in the morning, feel faint and 
are not able to eat breakfast ; on inquiry, it will often be elicited that they 
take no food, after a meal about six or seven in the evening, till breakfast- 
time ; an interval often of fourteen or fifteen hours, which is more than 
their powers will bear. They may be told to eat a piece of bread and but- 
ter about half an hour before going to bed ; they will then not only sleep 
better, but wake less languid. When there is much debility I have found 
advantage from ordering something before rising in the morning. 

The value of all treatment lies in its adaptation to the particular case. 
The distinction between the form of scrofulous affection has been drawn 
broadly and strongly ; they are not always, however, so clearly outlined ; 
but so convinced am I by experience of the advantages of separating the 
two sorts, both in diagnosis and treatment, that it appears to me impossible 
to insist too strongly upon their varieties. 

Local Treatment : First Stage. — Some little difference in the first applica- 
tion of local treatment will arise according as the surgeon sees the case 
quite early in the disease, or only after a certain time has been allowed to 
elapse. In the earlier part of the first stage there is no doubt, whatever 
may be the case afterward, that rest is the most, I had almost said the one 
important indication. To be beneficial this rest must be not only perfect, 
but must be combined with a good position. Hence, if it chance that the 
surgeon is first called in, when some malposture is already established, it 
will be his first duty to reduce the limb to a proper position. The mode 
of doing this, under the influence of an anaesthetic, has been already de- 
scribed (p. 56). I need only say here that, however fixed and immobile a 
joint in the early part of strumous synovitis may appear, while the patient 



STRUMOUS SYNOVITIS. 121 

is awake and sensible, the fixity always disappears, as soon as unconscious- 
ness is produced, and the surgeon may, without any force, place the limb 
in a proper posture, and affix such apparatus as he may prefer, be it splint 
or bandage. In a later part of this first stage, whenever such reduction 
becomes necessary, more power may have to be used ; at the same time 
great caution is necessary, since in joints, which have not deep cavities, as 
the knee, the radio-humeral, and shoulder (but here such replacement is 
very rarely necessary), a certain amount of subluxation is very readily pro- 
duced, more especially if the swelling be soft and large. 

When the proper posture has been gained, the limb must be carefully 
put at entire rest, either by placing it on a splint of metal, wood, or moulded 
leather, or by the use of a starch or plaster-of-Paris bandage. The value 
and mode of rest, the advantages and disadvantages of the immovable 
plaster-bandage, have been already discussed. I need only in this place 
more especially insist on the necessity of compressing the joint itself to a 
degree at least equal to the pressure on the rest of the limb. I believe 
myself to have seen several cases, in which such bandage became a means 
of injury, rather than of benefit, through the neglect of this precaution. 
Therefore I recommend in these cases that the joint be enveloped in one or 
two layers of cotton-wool, placed outside the flannel-bandage with which 
the limb is firstly covered, and that over this pad the plaster-band be 
strained more tightly than over other parts. Pressure, as we shall see im- 
mediately, is advantageous if it can be evenly applied ; smoothly arranged 
layers of the wool will graduate and regulate the compression of a well- 
applied bandage. 

One disadvantage of the plaster-of-Paris is its very considerable weight ; 
a drawback which is not felt if the patient is to remain in bed. But under 
certain circumstances, hereafter to be detailed, we may wish our patient to 
get about, even if the lower limb be affected, and we shall always desire 
such liberty if the joint be one of an upper limb. Hence in such circum- 
stances, the gum- or starch-bandage — which is exceedingly light but a little 
less firm than gypsum — can be conveniently substituted. Another draw- 
back may be that we cannot get at the surface in order ,to apply any further 
curative treatment. I use, therefore, irremovable apparatus only when the 
swelling is not very soft ; when the inflammation, being traceable to some 
definite irritation or accident, leads to the belief that the constitutional 
cause is less potent than in cases of independent origin ; or again, when 
certain signs show that other applications having been successful, and for 
the time sufficient, I wish to intermit them. Under such circumstances, 
the irremovable apparatus, insuring as it does a very perfect form of rest, 
is invaluable ; but the practice of putting up every inflamed joint in a 
plaster or dextrine case, and considering that herewith the ultimate word 
of treatment has been said, must be highly deprecated. 

In Germany, extension, or, as there termed, " distraction of the joints," ' 
has been abundantly used and extolled. The perception, that the cartilages 
most readily ulcerate where the two bones are in contact, has led to an 
exaggeration in the use of this treatment. The idea, that by such traction 
the bones could be drawn asunder sufficiently to make more room for the 
intra-articular effusions, and thus diminish tension, has been, strange as it 
may seem, seriously entertained ; now, although cartilages ulcerate most 
rapidly at the points of pressure, it is very doubtful if pressure ever pro- 

1 Volkmann's Neue Beitrage zur Pathol. Therap. der Krankheiten der Bewegungs- 
organe. 



122 DISEASES OP THE JOINTS. 

duces either the inflammation or the degeneration, which may lead to their 
destruction ; rather is it the fact that, these actions having been set in, the 
altered cartilage perishes more quickly under the influence of some com- 
pression. As to the influence of tension on articular capacity, my friend, 
Dr. Eeyher, 1 made some careful experiments by introducing a glass tube 
into the knee-joint through a hole bored in the pateUa ; the articulation was 
then filled with fluid, which was also allowed to occupy half the tube. A 
weight was then suspended on the limb, and the liquid in the tube rose 
considerably. Thus the capacity of the joint is absolutely diminished by 
" distraction," probably through tightening over it of the skin. At most 
joints (for the exception of the hip, see Chapter XTV.) weight- extension 
may somewhat diminish the contact pressure between the two bones, and 
thereby perhajus retard the disappearance of already inflamed or degenerate 
cartilage ; used with this design, it comes more properly under the second- 
stage treatment. It likewise is a method of obtaining rest and maintaining 
position; but other effects— antiphlogistic, absorbent, or otherwise — cannot 
be attributed to that treatment. 

In the first stage, then, of a strumous, as of other synovial inflammation, 
we must recognize, as the great essential of treatment, firstly, a good posi- 
tion ; secondly, total and entire rest, hot only of the joint itself, but of the 
muscles moving it. The means of obtaining this rest, and at the same time 
of avoiding injury to the patient's health, must be left to the judgment of 
the surgeon. As some aid to choice the following hints maybe useful: 
In cases which have begun in some traumatism, however slight, or, at least, 
with a distinct attack of pain at a definite time, the causation lies, probably, 
less in a constitutional cachexia, than when the contrary mode of commence- 
ment pertains — and this probability is heightened if the general signs of 
struma (p. 11) be absent, or, at least, not strongly marked. If, therefore, 
under such circumstances, the joint-enlargement be not of the peculiarly 
soft, doughy, and pseu'lo-fluctuating character, which indicates a great heap- 
ing up of embryonic tissue, it is probable that in such cases rest, as above 
defined, with attention to health, will effect a not too tardy cure. Let us 
take this class of case first. If the disease be situated in an upper limb we 
may, with much ease, follow out both indications, placing the segments 
above and below the articulation in a carefully applied starch- or dextrine- 
bandage, taking care that, at least, as much pressure falls on the joint as 
on the parts above ; we let the patient take sufficient exercise in the open 
air and use, if desirable, as is generally the case, some of the medicaments 
already mentioned. 

If, on the other hand, the diseased articulation be the knee or the ankle 
(hip disease is here omitted) such facilities for treatment do not exist. 
Under the circumstances, above postulated, I consider it, as a very general 
rule, wise to keep the patient a certain time in bed ; if the child be still 
small to apply a moulded leather or poro-plastic splint, extending well 
above and below the joint, and reaching more than half-way round the cir- 
cumference of the limb. If there be evidence of pain or of tenderness at 
its peculiar seat (p. 31) it is well to apply cantharides — not so as to blister, 
but to stop short of vesication — and to repeat it, alternating its position to 
different parts of the limb after the manner more fully described at p. 36. 
If, in from a week to six weeks, according to the case, these means have 
been successful in relieving the tenderness and somewhat reducing the 
swelling, the child may be permitted to get up, under careful arrangements 

■Deutsche Zeitschrift der Chirurgie, Bd. iv., S. 26. 



STRUMOUS SYNOVITIS. 123 

as follows : either the limb may be put in a starch-dextrine or water-glass 
bandage ; or, if it be thought that some local appliance may still be needed, 
in a well-fitting double case of leather or poro-plastic felt ; that is to say, a 
case consisting of two halves, one for the outer, the other for the inner 
aspect, so as to enclose and thoroughly support the limb, and yet be re- 
movable. The child may then be taken, if other circumstances permit, into 
the open air to lie down, or may, in some cases, even in this stage, be al- 
lowed a high shoe on the sound limb and crutch, after a method to be de- 
scribed immediately. 

A few modifications may be made according to certain circumstances. 
If the patient or his parents be in a position to be able to command car- 
riage exercise, and the sort of carriage needed, the child, instead of being 
entirely confined to bed, may be carried into the open air and placed in a 
proper recumbent or semi-recumbent position — or if at the seaside a boat 
may be available. However it may be most easily and beneficially managed, 
some stay in the open air should be obtained — but let me again repeat, 
with entire rest of the joint. When the monetary position of the patient 
places these conveniences within reach, the prognosis of strumous disease is 
far more favorable than when they are unobtainable. 

After an interval a certain arrest of the proliferating swelling takes place, 
and now a more stringent pressure should be used — a complete enveloping 
of the joint in strips of strong strapping plaster very tightly applied — swell- 
ing of the limb below being prevented by bandages — rubbing and other 
means also must be resorted to, of which more must be said in the sequel. 

If, however, the case be of a sort in which no traumatism —no definite 
beginning in an attack of pain — in which, perhaps, the mother or nurse 
has observed a swelling before the child complains, before he even limps — 
if, on examination, this tumefaction be found doughy, soft with false fluc- 
tuation and with distended surface veins — if the child, although, perhaps, 
amply fed, be ill-nourished — if he bear the evident marks of a strumous 
diathesis, the mere rest treatment, as above described, will have but little 
effect, and we must add to it other means. It is true that in a certain pro- 
portion of such cases all remedies will fail to cure the malady, but often the 
disease may be arrested ; and I need not say that, if local remedies are to 
be used, removable apparatus only are permissible. 

The treatment by blisters has been differently estimated at different 
times and by different people ; this, in part, depends on the choice of case 
and on the mode of use. To apply such remedy immediately over a super- 
ficial joint in a state of strumous disease is a mistake ; to prolong the appli- 
cation until the whole surface is vesicated a greater error ; to keep the blis- 
ter open with irritants is a barbarism. If it be applied, especially if kept 
on a long time, over a superficial joint, like the knee, it is likely to do harm, 
because the mere thickness of the skin divides the remedy from the disease, 
and the former is likely to overstep that limitation and augment the disease 
itself. The value of a counter-irritant is almost, if not entirely, limited to. 
the interval during which redness of the skin lasts, and it nearly ceases 
when vesication is complete. This impression should be conveyed through 
the nerves (we all know how useful blisters are in some forms of neuralgia, 
and of pleuritis); hence, in each joint the counter-irritation should be ap- 
plied over the course of the nerves, which chiefly give supply to the joint — 
first, over one, then, as the skin recovers, over another, and so on till we re- 
commence at the beginning of the series. Other modes of exciting counter- 
action are the strong nitrate of silver solution painted on the joint itself 
every other day, or sometimes everv day. The action produced by this 



124 DISEASES OF THE- JQINTS. 

drug' extends but very little way from the place of application, does not, 
therefore, easily pass inward to the inflamed tissue itself ; it is different 
with iodine, the inflammatory result of this chemical spreads deep, hence 
its stronger solutions should be used like cantharides. 

The inflammatory hyperplasia of strumous synovitis comes, after some 
time, to an end, and then there is in most cases a phase of inaction (p. Ill), 
during which the embryonic tissue seems undecided whether to take the 
downward route to degenerative or the upward to formative acts. The 
surgeon's aim, I must more strongly accentuate it, the surgeon's duty is to 
detect this phase, and to insist on taking the ruling part in the decision. 
"When tumefaction ceases to increase, the special spots of pain must be 
questioned, and the other symptoms be thoroughly examined. If the signs 
of active inflammation have ceased, the real state of the new tissues is one 
of sluggishness ; any action must be better than mere idle falling to decay. 
Under such circumstances, all those manoeuvres known under the name of 
" shampoo " are often followed by even unexpectedly good results ; espe- 
cially should those acts which compress the tissues and direct their super- 
abundance in the course of the venous or lymphatic currents be employed ; 
and these may be used in the commencement for five minutes once in the 
day, then twice in the day, and then the time of each occasion may be grad- 
ually prolonged. 1 

With this treatment firm compression of the joint should be combined, 
the most convenient means being the elastic webbing bandage, which, in 
the intervals of the shampoo, is to be applied with cautious tightness ; over 
it the splint or double leather case should be adapted. 

Of passive movement, and its possible applicability in this stage, I shall 
have to speak immediately. 

Another treatment, of which I think very highly, is the injection into 
the diseased tissue of iodine solutions. 2 I first used these methods in 1872, 
and have very frequently employed them since with, in many cases, much 
advantage. The strength of the solution may begin with half a drachm of 
tincture of iodine to seven and a half drachms of water, and may gradually 
increase to two or even three drachms in the ounce. A syringe, holding 
about half an ounce, fitting into a tubular needle, rather longer than the 
usual hypodermic needle, and with lateral as well as terminal perforations, 
may be used. The syringe being filled, the needle is adapted to its nozzle, 
air excluded, and then the surgeon passes, a little beyond the first lateral 
perforation, his needle into the softest part of the tissue, but avoids enter- 
ing the cavity ; the needle, therefore, should take an oblique course, there- 
by traversing as much tissue-substance as possible ; a drachm, or a little 
less, may be injected in one spot, and the surgeon can, if he think well, 
select another on the opposite side of the joint ; or, by directing the obli- 
quity of the needle in a different course, inject more tissue from the same 
puncture. My d, priori reasons for trying this method were a strong per- 
ception of the indolence of these tumefactions, and a desire to imitate in 
them the remedial measures so often used in sluggish ulcerations. .When, 
for instance, such a sore neither spreads nor heals, but simply remains in 
the state of granulation, we excite it by stimuli and irritants to some form 
of action, which shall lead to cicatrization. The results of this deduction 
have by no means disappointed me, but, on the contrary, a great many 
cases thus treated have been led to a good issue, and I have never found 

1 See Mosengeil, Verhandl. d. Deutsoh. Geaellaoh. f. Chirurg.. 4th Congress, 1875. 
5 See my paper in British Medical Journal, voL ii. , 1874, p. 4S9. 



STEUMOUS STNOVITIS. 125 

harm result. No pain beyond the mere needle prick is produced. Imme- 
diately after the injection, pressure and the splint should be reapplied. In 
a day or two, if the remedy be fulfilling its object, the parts over the in- 
jected spot will be found slightly harder, a little more condensed, and in 
the best cases even a little depressed, the fibrillating tissue having drawn 
the skin inward. The injection may be then repeated at intervals of three 
or four days in other parts of the circumference.' Iodine, however, is the 
best basis ; any variant, such as carbolic acid or nitrate of silver, if used at 
all, should be only exceptional. Iodine has a greater power of dissemina- 
ting itself widely among the granulation-cells than any other fluid, with 
which I have experimented, moreover it has no tendency to excite suppura- 
tion, but rather induration and thickening ; it is these qualities which make 
it of special value. 

"When a certain definite consolidation has been obtained, and on that 
account, or because sufficient activity of the tissues has been produced, 
pressure becomes extremely valuable, especially if combined with some 
slow rubefacient or irritant action on the skin. Of course any bearable 
amount of pressure can be attained by means of the elastic bandage, but it 
is apt in a little while to slip, to become loose, or to be loosened ; hence an 
adhesive form of plaster is preferable. The joint should be strapped with 
strips of such material firmly and strongly in the manner already described. 

Passive movement is also, in a certain number of these cases, remedial ; 
we must be quite sure that inflammation has ceased, that the period of 
inaction has arrived ; if that point be clearly ascertained, such motion of 
the joint, during shampooing, is to be employed for a short time daily, and 
then, as in these other recommendations, the splint is to be replaced. The 
difficulty lies in getting all this properly done, and not overdone ; the pa- 
tient should be visited at not long intervals, and the measure of the joint 
taken on each occasion ; if it decrease, good is being obtained, if it in- 
crease, the treatment has been premature or too energetic ; absolute iden- 
tity of size shows, at all events, that no fresh inflammation has been lighted 
up, and is a hopeful sign, since the tissue, which is not proliferating, will, 
under these circumstances, surely cicatrize. 

The maintenance of the general health is a great essential, and if the 
disease be in the lower limb continuance of the entire rest-treatment in bed 
is extremely likely to frustrate any efforts we may make in this direction. 
A child with a shoulder- or elbow-joint disease may go about, and, preserv- 

' It is a singular coincidence, that while I was trying the injection of these fluids, 
not as remedies for inflammation but as exciters of action, Dr. Hiiter, of Greifswald, 
was beginning to use an injection of carbolic acid as an antiphlogistic. He published 
his practice, and the theory on which it was founded also, like me, in 1874 ; and in his 
work on Joint Diseases, second edition, 1st part, p. 206, states that his " New method 
is founded on the experience that the local application of aqueous solutions of carbolic 
acid to inflamed wounds renders " most valuable antiphlogistic results ; " hence he de- 
rived the idea that the same antiphlogism would follow moistening internal tissues 
with the same material. In his journal, the Zeitschrift fiir Chirurgie, Bd. iv., p. 
308, is a description of the instrument he uses, and of very brilliant results. I have, 
led by this idea, given these injections a full trial, but am sorry not to be able to con- 
firm Dr. Hiiter in his estimate of their value, finding no antiphlogistic virtue in car- 
bolic acid injections. Nor does it seem to me that the reasoning is well founded, since 
that material applied to a wound is not an antiphlogistic ; it may render innocuous 
certain other matters which if left alone would excite inflammation, and hence in a 
secondary and indirect way will be adverse to certain forms of such action ; but i; s 
direct effect is irritating, tending rather to produce inflammation, and the noxious 
matters against which it guards open wounds, are not to be found in the substance of 
tissues unexposed to the air. 



126 DISEASES OE THE JOINTS. 

ing a good general condition, is more likely to carry the joint disease to a 
favorable end than one who, suffering from knee disease, is kept in bed. 
A device by Mr. Thomas enables us, in a certain degree, to obviate this 
difficulty ; viz., the child is to have a high shoe or a patten or an ordinary 
high boot on the sound foot, and a pair of crutches. The diseased limb, 
properly supported by some form of splint above described, swings free of 
the ground and bears no weight ; the child taking exercise — not, it is true, 
in a veiy pleasant way — and getting out of doors, maintains a bodily health, 
in which suppurations are less likely to supervene than when the general 
condition is depressed by confinement. The patient should not be allowed 
out of sight and reach till he has perfectly learnt to use the crutches, only 
a certain amount of exercise is to be granted, and he must be constantly 
watched, lest he get into some trouble by a fall. All these points create 
some difficulties ; and another obstacle, not unfrequently among the well- 
conditioned, is a great dislike to seeing one of their children going about 
in the manner described. In making his choice between this form of treat- 
ment and entire rest in bed, the surgeon will have to exercise all the care, 
acumen, and judgment that he possesses. One thing I should like to add, 
if he have used these qualities, and have duly watched results, and never- 
theless the joint fall into severe disease, he need not of necessity consider 
that he has been wrong ; although the parents are pretty sure to do so ; a 
certain proportion of these cases are founded on too pronounced a consti- 
tutional evil to do otherwise than ill. 

The Second Stage requires, as long as its chief symptom and distress, 
viz., starting pains, continue, entire rest in bed. As the condition is impli- 
cation of the cartilage and of the bone, I would refer the reader to the 
chapter on Strumous Ostitis for a more detailed account of its management. 
In this place it appears only necessary to refer to certain points in which 
the two differ. In this stage extension of the joint is often of great advan- 
tage, especially at night when the starting pains are most severe, the pulley 
and weight may be used for joints of the lower limb, more especially of the 
hip and knee ; such treatment for the shoulder and elbow is more difficult 
of application, and is less important, nor are, as we have seen, starting pains 
as severe. Splintage and utter rest are of course necessary. If in spite of 
this the evil continue to increase, we have a resource to be sparingly em- 
ployed, viz., the actual cautery. This remedy, which at the first mention 
seems cruel, is in properly selected cases very merciful. I have seen pa- 
tients who have had no uninterrupted sleep for weeks, rest quite placidly at 
night after this appliance ; also children, who previously could scarcely 
allow any one to approach the bed, laughing and playing directly after- 
ward. Indeed, the immediate effect of the hot iron is to allay these pains 
in a very singular manner, and this remission lasts for from three days to ten 
days, and then in some cases the trouble sets in again, unless remedies, to 
be taken in the meantime, have had a beneficial effect, or unless repetition 
be possible. 1 The iron should be at a white heat, and a single line, not too 
long, be drawn with gentle pressure and rather slowly in the axis of the 
limb. It is well to let the line occupy as small a space as may be consid- 
ered can have any effect. Afterward the part should simply be dusted 
with oxide of zinc powder and covered by a thin layer of cotton-wool, and 
when separation of the slough begins, healing should be procured as quickly 
as possible ; the suppuration appears not to be the beneficial agent, but the 
actual skin irritation. The same thing may be said of caustic issues, etc., 

1 For the method of using the iron, see Chapter XI. 



STRUMOUS SYNOVITIS. 127 

a long-standing suppurating sore is undesirable. If starting pains be com- 
bined with malposture, they may at first increase when the position is rec- 
tified, since the muscles (flexors) are thereby rendered more tense ; hence, 
section of one, or even of more, tendons may be desirable : this remark ap- 
plies especially to the knee and to the ham-strings, but as a rule bromide 
of potassium has great influence in obviating the effect of tension after re- 
position. 

As to internal remedies ; opium or morphia in sufficient doses, when ab- 
solutely necessary, will procure sleep ; but those drugs do not appear to 
have much beneficial influence on the spasmodic muscular twitching. I 
have more than once seen, and oftener been assured by the nurse, that 
«ven while the patient was slumbering the limb started. In some cases 
moderate doses of strychnia have considerable effect, and in a greater num- 
ber bromide of potassium exercises much influence over this symptom. I 
prefer trusting to one or the other of these alternately ; to give opium for 
pain which must be expected to continue a long time is a doubtful proceed- 
ing ; the drug may, however, be reserved for an occasional emergency. 

Here, and in concluding this account of different modes of treatment in 
the two first stages of this malady, I must state that no amount of granula- 
ting or fungating disease, as yet not suppurating, can in my opinion justify 
removal of the joint, either by excision or amputation ; as long as the new 
tissue is simply a tissue, not a bag of pus, nor a collection of abscesses, 
even though the cartilages may have given way, so long may we still enter- 
tain hopes of preserving the joint, anchylosed perhaps, either truly or falsely. 
Widespread suppuration and caries put the case on a different footing, but 
mere strumous enlargement, with one or even two small abscesses, does not 
warrant either of the above radical measures. 

Thied Stage. — The degenerating or suppurative aspect of the third 
stage requires management which will differ considerably, according as 
those actions are rapid or slow, widespread or limited in extent — in either 
event we have abscess to deal with, intra-articular, peri-articular, or adja- 
cent. If the pus-formation, either by secretion from, or decadency of the 
granulation-tissue, be so rapid as to produce tension, we must, whether 
this be intra- or peri-articular, take some means of relief. The less severe 
procedure, and that which I advise in any case, not too greatly depressed 
or exhausted, is to evacuate the cavity under pressure. The aspirator does 
not answer here, the flocculi being too many and too large to pass through 
the needle ; but if an elastic bandage be put rather .tightly round the joint, 
leaving a small interval where the pus seems most superficial, and if through 
this a narrow-bladed straight bistoury be passed, the pus will readily flow, 
more especially if the flat of the blade be deftly used to hold the wound 
agape. This should of course be done under the spray, and the wound is 
to be dressed antiseptically ; whether or no a drainage-tube be passed in 
must depend on the surgeon's opinion concerning the entire evacuation or 
the probable rapid fresh formation of purulent fluid. When the cavity is 
quite empty and the little wound dressed, strong pressure should be em- 
ployed. Hyperdistention by injecting the cavity with a three per cent, so- 
lution of carbolic acid, by means of a ten-ounce syringe through an india- 
Tubber tube (a gum-elastic catheter answers best), has proved in my hands 
beneficial, especially if the abscess be intra-articular. 

Jf while the patient's health is rather depressed, degenerative actions be 
pretty rapid and widespread, it is often better to make a free incision into 
the abscess in as depending a part as possible ; if this be done under the 
spray no feverish reaction results ; and one may even introduce a properly 



128 DISEASES OE THE JOINTS. 

prepared (antiseptic) finger into the wound and remove those parts of the 
tissues, which, being soft enough to come away easily, are evidently degen- 
erating. Such an opened abscess is to be treated without much reference 
to its being in a joint (save the splintage or extension), which has abro- 
gated its peculiarities as a highly irritable organ ; namely, it is to be al- 
lowed to heal by granulation from the depths, and any application likely 
to promote this object, stimulant or astringent, may be used. I have on 
several occasions seen the best results follow such treatment of joints, 
which must otherwise have been removed. Some surgeons, when they have 
opened up a joint thus diseased, use a rather strong application, sulphuric 
acid diluted with an equal bulk, or twice the bulk of water. The method 
is rather too heroic, and although a certain number of patients have got 
wel} after this treatment, a good many have succumbed. Simple opening 
up of the cavity, or cavities, answers all purposes, unless there be deep ab- 
scess in the bone, which is usually the result, not of synovitis but of ostitis, 
and which acid used as above will not cure. 

Adjacent abscesses, more especially those that run along the bone, are 
very difficult to treat ; if they communicate, as they occasionally do, with 
other abscesses about the joint, the limb should be bandaged, a pad being 
placed over the track of the abscess, so as to press out the pus and prevent 
the further spread upward of the morbid action. If the abscess do not 
communicate, its lower or upper end should be opened, according as it is 
in the upper or lower segment ; it should then be padded and' bandaged 
toward the opening. Hyperdistention, with either iodine or carbolic acid, 
is sometimes useful. 

In a certain number of cases, in spite of all skill, the disease continues 
to get worse ; bone debris and portions of sloughed granulation, or ligament- 
tissue, come away with the discharge, the joint is evidently destroyed, and 
the question arises whether or no being retained its disease will destroy the 
patient. My experience at two institutions for cripples shows that patients 
may get well after an almost incredible amount of joint disease ; but I do 
not see at those places the numbers who do not get well. Our treatment 
too in hospital and in private practice cannot be quite similar ; in the for- 
mer, time is a very considerable factor, while wealthier people can afford 
to lie by, or let a child lie by, for three, five, or even more years, in prefer- 
ence to undergoing an operation. Yet, occasionally, in both classes of prac- 
tice, signs after a time arise that the choice lies between loss of joint or of 
life. These are fully discussed in the sequel. 

The other phase of the third stage, viz., repair, may supervene at any 
time, either after suppuration has produced considerable changes, or be- • 
fore any such action has commenced. If no abscess exist, the diminution 
in size of the swelling, and reappearance of normal bony prominences, 
should warn us not to permit the joint to become unnecessarily stiff. I am 
certain that many a stiffened joint ought to be avoided. Kubbing, passive 
movement, etc. (see p. 124), may be safely employed with due caution, 
while consolidation is hastened by pressure. The same may be said when, 
after abscess, the sinus mouths are healing, but even more circumspection 
is then required. Again, if certain events threaten true anchylosis, more 
vigorous movement may be used. The surgeon is to discriminate between 
such cases whose best termination is true anchylosis, and such as are sus- 
ceptible of something better. At all events, let him watch that the joint 
may lie in the most convenient posture, if it is to be stiff ; or may enjoy 
such restricted motion, as can be retained, in the most advantageous part 
of the normal arc. 



STRUMOUS SYNOVITIS. 129 1 

Case XXXII. — Miss W., aged five, was sent to me on February, 1878, by 
Mr. Marsack of Tunbridge Wells. She was a child of rather strumous as- 
pect, and of marked strumous descent. The cause of her coming was an 
affection of the right knee, which was observed two months previously to 
have become swollen. About three weeks after this had been noticed, a 
slight limp began, and some expression of pain was elicited. These latter 
symptoms grew worse, and at the above date the child was brought to me. 

I found the knee markedly swollen, rounded, shapeless, soft. In walk- 
ing, a decided limp occurred, and the child gave evidence of pain. The 
following measurements were taken : 

Sound knee. Diseased knee. 

Above patella 8f 9£ 

Across " 9| 10 

Below " 8£ 8f 

I recommended a double leather case, painting the joint freely with ni- 
trate of silver lotion, iron and iodine. 

In two months the joint was of much the same size, but pain in the 
place of election was pretty strongly marked. The limb was placed in 
plaster-of-Paris, and the child under Mr. Marsack's superintendence evi- 
dently improved. After ten weeks that gentleman removed the plaster- 
bandage. He wrote to me that, although the joint was certainly better, it 
had not so far progressed as to induce him to change the form of applica- 
tion ; therefore on the next day, i.e., in the beginning of July, he again 
put on a plaster-band, and the child went to the seaside. 

October 7th. — I saw Miss W. again. Mr. Marsack agreed with me that 
the joint was now sufficiently free of inflammation to permit of some pas- 
sive movement and rubbing. Accordingly, a single leather splint was 
adapted on the outside of the linib. This was to be removed night and 
morning, the limb moved and rubbed for ten minutes, and then the splint 
reapplied. Gradually the time of rubbing, etc., was to be increased, and 
after a period, which Mr. Marsack would indicate, some walking with the 
splint on the limb might be allowed. 

January 6, 1879. — The joint had almost entirely regained its form, and 
the movements were but very slightly restricted. She was allowed to walk 
a little without the splint, rubbing was to be continued, and passive move- 
ment of the leg to be carried out. At night splint to be reapplied. 

April. — The knee was perfectly well. 

In cases seen later a persevering course of treatment may effect much. 
Fortunately in the following the suppurative action was not deep, neither 
was it general, and pressure succeeded in consolidating the tissues. 

Case XXXHL — John , aged seven, a light-haired, pale, strumous 

boy, was brought to me by Mr. Watkins, jun., of Chandos Street, April 2, 
1860, with a strumous inflammation of the ankle-joint. This complaint was 
of three years' duration, and appears to have been brought on by an injury 
inflicted by a large, heavy woman, in thick boots, having stepped back upon 
the child's foot ; at all events, he has not been able to walk since that acci- 
dent, and the ankle has been gradually swelling more and more. The diffi- 
culty of diagnosis is increased by some amount of malformation, so that the 
sound joint even looks a little distorted ; the internal malleolus is very 
large, and the tibia, from a little above the joint, slopes outward and be- 
et 



130 



DISEASES OF THE JOINTS. 



comes very small ; the axis of the ' leg is thus directed inward, and that of 
the foot outward. 

The diseased ankle, however, was very much enlarged, as may be seen 
by an examination of Fig. 15 ; the tumor was soft and pulpy and extended 
in a smooth, even manner around the whole joint ; was most marked at the 
back, but nevertheless was very considerable under and around the malleoli, 
also, in front, concealing the markings of the extensor tendons ; the rest of 
the foot was thin, and the limb above the affected joint was wasted, show- 
ing in strong relief the puffy, ill-conditioned enlargement, at the back of 
which there was a red, inflamed spot where pus had formed. The difficulty 
of diagnosis referred to consisted in the deformity and large size of the in- 
ternal malleolus, which much militated against any certain judgment as to 
•whether or not the bone was affected. Finding, however, that moderate 




Fig. 15. — Strumous synovitis of ankle. 

pressure on the bone produced no pain, and that although misshapen, it was 
as near as could be judged of the same shape as the other, I was pretty 
confident that the bone was free of disease. 

April 2d. — A puncture was made where the skin over the suppurated 
part seemed thinnest, i.e., over the Achilles tendon ; a bandage was then 
applied, strongly compressing the tumor, but leaving the wound uncovered, 
and he was ordered to take a drachm of cod-liver oil, with iodide of iron, 
thrice in the day. 

April 6th — I saw the child again, and Mr. Watkins agreed with my idea 
that, the disease being & strumous inflammation in the sluggish stage, pres- 
sure fairly applied offered us the best chance of securing the absorption or 
fibrification of the morbid growth ; therefore the foot and ankle were tightly 
and smoothly strapped, after Scott's method, with the resin plaster, leaving 
the open wound uncovered, and he was ordered to continue the cod-liver oil 



STRUMOUS SYNOVITIS. 131 

April 13th. — The strapping haying become loose it was removed ; the 
swelling was considerably decreased. 

May 25th. — Mr. Watkins continued to attend this patient since the last 
date, carefully and skilfully carrying out the plan of treatment which had 
been laid down ; the child's ankle was much reduced in size ; there was no 
pain on pressing the tumor, nor the bone, nor on pressing the joint-surfaces 
together ; the limb was again strapped ; pads being necessary under the 
malleoli. 

June 9th. — Still going on well as far as the ankle was concerned ; ■ the 
tumefaction diminishing, and there was no pain ; the cod-liver oil no lon- 
ger agreed ; it seemed to diminish appetite ; the weather was getting warm ; 
he was ordered to try cold bathing in the morning, if he remained chilly 
after it to use it tepid at first ; to take three grains of the ammonio-citrate 
of iron ; the ankle was again strapped. 

July 3d. — Has been under the care of Mr. Watkins ; the same plan of 
treatment was carried out, and with such success that the tumefaction had 
greatly decreased, indeed, the ankle was very nearly the same size as the 
other ; he could bear pressure on the bottom of the foot as strongly as I 
could produce it with my hand, and this did not give him any pain ; but I 
could not persuade him to put any weight on it in walking. The cold bath 
had not been used ; he looked pale and worn, but his appetite was very 
much better ; the ankle was again strapped with pads under the malleoli ; 
the cold bath was insisted on. 

August 13th. — The boy was brought to me twice since the last date ; the 
ankle was not at all painful ; the wound at the back had healed, but the 
boy was so nervous that it was very difficult to make him put the heel 
properly to the ground, although I could, without giving pain, press the 
foot upward very firmly, forcing the articular surfaces together more strong- 
ly than his weight would do. 

Shampooing and cold douche ; motion passive and active. 

I saw this patient on September 24th ; his leg was still thin and weak, 
prevented his walking without support, but the joint was perfectly sound 
and the limb was gaining strength every day. 

Case XXXIV. — I was requested to see Miss F. B., aged seven, on May 
3, 1877, with a strumous disease of the knee, which had lasted just over ten 
months. The disease began by swelling, which at first was painless and 
caused no limp. After a time some lameness set in. By advice it was 
painted with iodine, and then poulticed ; a straight, wooden, flat splint was 
bandaged on the back of the limb ; but the little girl was rather spoiled 
and indocile, while the gravity of the case was, I fear, hardly recognized. 
Meanwhile lameness increased, as also did pain ; the child was kept to bed ; 
the same splint was kept on till two days ago, when the child declined to 
wear it longer ; she was in great pain, and her sufferings increased. Dur- 
ing the night of May 2d she hardly slept, but kept crying and even shriek- 
ing with pain. 

On the morning of May 3d, I found her propped in bed with pillows, 
worn-looking and frightened, begging me not to touch her knee, and grasp- 
ing the lower part of the thigh with both hands. The joint was flexed to 
a very acute angle, swollen, rounded, and shapeless. I could find no sup- 
puration, but the examination was most unsatisfactory. I obtained permis- 
sion to have chloroform administered, and during the afternoon, under its 
influence, the limb was straightened without the least force, and bandaged 
upon a Maclntyre splint. Examination of the limb showed a very soft en- 
largement, completely concealing the form of the bones. There was pseudo- 



132 DISEASES OF THE JOINTS. 

fluctuation at almost every point of the enlargement, but I convinced myself 
that no pus had formed anywhere sufficiently near to be detected. 

May 4th.— She was very much easier, when she awoke from narcosis, 
and slept soundly until about 4 a.m., when she complained of pain at the 
back of the knee and thigh (tension of ham-strings) ; seven grains of bro- 
mide of potass, prescribed for this event, calmed her, and she slept till late. 
On my visit I found her comfortable. Painting with nitrate of silver solu- 
tion, eighty grains to the ounce, night and morning, was ordered, with di- 
rections to recur to the bromide if pain should return. 

May 19th. — The paint had to be twice intermitted ; the limb was pain- 
less ; but two spots of tenderness were detectable — one at its usual seat, the 
other over the outer tibial tuberosity. The skin was still rather irritated, 
A layer of wadding was placed over the joint, and tight strapping applied ; 
limb below bandaged. 

June 2d. — Strapping removed ; joint smaller — but the false tissue still 
soft ; injected in two places with tincture of iodine and water, forty min- 
ims to the ounce ; this injection (afterward increased in strength) was em- 
ployed twice a week for three weeks, at the end of which period the knee 
was considerably smaller and much harder. Pressure with elastic bandage 
was then resorted to, and for a fortnight the injections discontinued. 

July 6th. — The knee slowly decreasing in size ; injections resumed, con- 
tinued weekly for a month ; one and a half drachm to the ounce. A double 
leather splint was moulded on over the elastic band. On the 10th she was 
allowed to get up ; on the 14th she took a drive with the limb on a pillow. 

By slow degrees the joint improved ; she went to the seaside at the end 
of August, but with injunctions not to put her foot to the ground. She had 
crutches, and moved about a good deal — walking and driving. 

October 2d. — The joint measured the same size as the other, butit looked 
larger on account of shrivelling of the thigh and leg ; the arc of movement 
considerably restricted. Passive movement and rubbing ; then resumption 
of the splint ; afterward swinging soon gave greater freedom. 

At the beginning of the year 1878 the limb could be bent to a right 
angle — she could kneel. The joint measured, above the patella, § inch less 
than the other. In June, 1878, when I again saw this patient, it was diffi- 
cult to find any remains of disease, which were inability to get the knee 
perfectly straight, and to bend it till the heel touched the buttock, which 
the other could do. 

Case XXXV. — I was asked by Mrs. T. to see her daughter, aged seven- 
teen, September 30, 1859, with a diseased knee of four years' standing. 
She has dark long hair ; a white transparent skin ; very white conjunctivae, 
long dark lashes. Her health was a good deal broken by long confinement. 

At school, rather more than four years ago, her knee became painful ; 
she may have hurt it, as she was very fond of running and other exercise, 
but does not remember it. When the knee became painful it swelled She 
remained at school about three weeks, and then was sent home. A paste- 
board splint was applied to the leg and the joint was blistered ; had two is- 
sues, one after another, and the knee got so much better that she could return 
to school, but had always to wear the splint ; could walk with, and after a 
time without a stick. Eight months ago she fell down two or three steps 
and hurt her knee very much ; it swelled again, slowly, and an abscess 
burst at the inner side just below the head of the tibia ; a little afterward 
she had starting-pains at night, and a week or so later these occurred also 
in the daytime, and they continued to do so. She desired nothing so 
much as that these should be stopped. 



STRUMOUS SYNOVITIS. 133 

There was a rounded swelling, without definition of edge, at the knee ; 
the mouth of the sinus still open ; marks of issues, one on inside, one on 
outside of knee ; the joint was tender and she had starting-pains ; the joint 
could he flexed a little without causing any severe pain or producing any 
grating, but it could not be straightened ; it was in very fair position, but 
rather too much bent. Her mother had taken up residence in town, hav- 
ing come from shire. 

October 3d. — The long-continued starting-pains, showing that the car- 
tilages were undergoing ulceration, would not allow us to hope a restora- 
tion beyond false anchylosis ; the first object was to stop these pains ; 
divided the flexor tendon with long tenotomy knife, and fastened a Liston's 
splint at back of the limb with well-padded straps and bandage ; to have 
at bedtime half a glass of sherry with fifteen drops of laudanum. Slept 
better ; had one or two little starts toward morning. 

October 7th. — Had less starting-pains since the first night ; had taken 
no opium since then, but had continued the sherry ; thought it produced 
acidity ; did not like wine. Ordered to take two tablespoonfuls of the 
mistura ferri composita three times a day. Cold water to be applied. 

I took the limb off the splint, and by manipulations got it straighter 
and put it on the splint again. 

October 12th. — Every other day the screw has been turned half round ; 
the joint was nearly straight enough ; strapped the knee, leaving the 
mouth of the sinus uncovered ; to continue turning the screw in the same 
way. 

October 19th. — A letter informed me on the 17th that the lady thought 
her daughter's knee was as nearly straight as I had desired it to be made, 
and there was a little pain in it ; I happened not to be able to go till to- 
day ; the pain was at the back of the joint, and had nearly gone off ; the 
strapping had quite driven away the slight recurrence of starting. Ordered 
a leather splint for the outside and inside of the limb ; strapped the knee 
still more tightly ; to leave off the night draught. 

October 28th. — The splints were applied and the knee felt very com- 
fortable ; she may now get up and move about on crutches. 

November 7th. — Had been going on much the same ; the swelling was 
very much reduced and was harder ; there was still a slight amount of 
tenderness, particularly over the inner condyle of femur : to continue in 
the same manner. The mouth of the sinus nearly closed ; hardly dis- 
charged ; put in a shred of lint to prevent too early healing. 

November 11th. — Was sent for ; the discharge from the sinus had in- 
creased, and the startings had returned as bad as before ; proposed the 
cautery and agreed to go next day and use it. 

November 12th. — Chloroform administered ; two lines of cautery four 
inches long, one on each side of joint ; Liston's splint again ; repeat night- 
draught. 

November 19th. — Had hardly any pain on recovering from the chloro- 
form ; the startings entirely ceased when I saw her the day after. — The 
eschars separating : to dress the lines with zinc dressing, tightly band- 
aged. 

Ordered to take of cod-liver oil one teaspoonful and two grains of qui- 
nine thrice a day. 

November 29th. — The starting-pains had not recurred ; the lines of 
ulcer from the caustic were beginning to contract ; the granulations were 
small and pointed. 

December 12th. — The caustic lines very nearly healed ; joint strappel 



134 DISEASES OP THE JOINTS. 

and leather splints reapplied. As it was probable that want of care, iu 
bearing too much weight on the limb, caused the last relapse, I have not 
allowed her yet to get off a sofa-bed which she used. 

December 22d. — At this date permitted her to get up and go about 
with crutches, but she was to use a stirrup for the foot, fastened to the 
waist by a band of the proper length to keep the foot from the ground ; 
there is now hardly any, if any, tenderness over the inner condyle, the 
sinus has healed. 

January 31, i860. — I have seen this patient once or twice ; her health 
was much improved and she had gained flesh ; there was, absolutely, no 
tenderness, and the joint was as nearly as possible the same size as the 
other ; the patella could just be moved, latterly, by grasping it in the lin- 
gers, without pain ; a slight crepitation, not bony ; produced very slight 
passive motion in the joint without pain ; showed her mother how to 
move the limb, and directed her to do it, so as not to cause pain, every 
morning ; the strapping, also, was discontinued, and the joint to be sham- 
pooed, rubbed with oil, and bathed with hot water ; the splint to be reap- 
plied after these manoeuvres ; to leave off the stirrup. 

March 3d. — Have seen this patient three times ; the limb had more 
mobility and was not tender ; she put the toes to the ground in walking, 
and bore a little weight on them ; the joint was anchylosed (false anchy- 
losis) ; passive motion to be used with a little more energy. 

This young lady was at this time able to bend the limb and straighten 
it again voluntarily, to a fair degree ; she walked with a stick or umbrella 
by means of a high-heeled shoe ; more might be done toward getting a 
flexible joint, but she was rather unwilling to have any further attempt, at 
all events for the present. 

Case XXXVI. — Daniel Hogan, aged thirty, a dark-complexioned man, 
rather above middle height, young-looking, a machineman at a printer's, 
came to me March 20, 1860, with a bad elbow. 

About fifteen years ago he twisted the left arm in some game ; it was 
painful, and in a few days swelled ; he went to King's College, they applied 
blisters and iodine, the swelling at the inner side increased and it was 
lanced ; some pus flowed. Before the skin was well, however, he went to 
Mr. Verral, who put on a splint ; and then to St. Bartholomew's under Mr. 
Skey, who leeched it, and in about a fortnight lanced an abscess which ap- 
peared at inner side of upper third of forearm. All this took place in 
about a year or eighteen months ; motion of the arm was painful, but I 
could not make out whether or not the inflammation was in the joint ; at 
all events, he got so well that for the last fifteen years he had been machine- 
man at a large printing-office, having frequently to lift heavy weights, as a 
form full of type, and, owing to a smash of the right hand, had used the 
left one most. Five months ago he had a swelling form at inner side, just 
beldw elbow, which got rapidly bigger, and in three weeks became very 
painful ; he went to a medical man in the Waterloo-Bridge Boad, who 
lanced it ; the pain was a heavy and bursting pain. A month ago starting- 
pains came on. 

March 20th. — The elbow-joint was much swollen ; the swelling con- 
cealed the shape of the bones, was rounded and shapeless ; the arm above 
thin ; the tumefaction was evidently in and around the joint ; it presented 
a false sense of fluctuation, which is characteristic of strumous synovitis; 
the skin was red at inner side and below elbow, where there was an open- 
ing discharging pus : a probe passed into it entered the joint, but did not 
come in contact with bare bone ; he could not bear the slightest move- 



STRUMOUS SYNOVITIS. 



135 



ment or pressure of articular surfaces together. A gutta-percha splint was 
applied on the outside of the arm bent at more than a right angle ; cod- 
liver oil and quinine administered internally. 

April 12th. — Drawing made from elbow. 

April 14th. — Nothing of importance to record ; the arm had increased 
in size, and the starting-pains had become more marked ; these pains pre- 
vented his sleeping at night ; his looks had become worn and haggard ; a 
a part near the inner condyle fluctuated so distinctly that I punctured it ; 
no pus escaped ; I put my little finger into the wound, felt soft jelly-tissue 




Fig. 16. — Strumous Bynovitis of elbow (advanced). 



all round ; a portion of this was extracted, examined beneath the micro- 
scope, nearly all the cells were found crowded with oil-globules ; there 
were a great many free ones lying among the cells ; to this formation was 
doubtless owing the fluctuation. It was explained to him that hardly the 
faintest hope existed of saving the joint, and he was advised to permit its 
removal : he wished to postpone this. With a view of trying to prevent 
the starting pain the joint was tightly strapped. 

April 16th. — He had, after being strapped, a couple of the starting- 
pains, but none afterward ; has slept very well. He told me to-day, for 
the first time, that for about a month past, whenever he leant in a certain 



136 DISEASES OF THE JOINTS. 

way upon the elbow, he had had a peculiar sensation, as though one bone 
slipped or glided over the other out of place. 

April 30th. — He continued to be quite free from the starting-pains, and 
his looks had very much improved ; the elbow was reduced in size and 
harder, but the last few days he complained of pain over the outer con- 
dyle ; an abscess, very superficial but of large extent, was found ; the skin 
was discolored and evidently separated from the subjacent tissues for some 
distance ; it was freely incised ; bled smartly, to stop which pressure was 
applied. 

May 2d. — The part of skin which was previously blue and discolored 
had ulcerated ; the sore was oval, about an inch and a quarter long 
by three quarters broad ; the upper arm was swollen ; strapping applied 
more tightly. I learnt, in the earlier part of the case, that this man was 
able to live pretty well, having, it appeared, saved a little money, but it 
was now exhausted ; he was evidently badly fed. 

May 9th. — The upper arm was swollen, with deep, hard tumefaction ; 
again examined the limb carefully and passed a probe along sinus at inside 
arm ; it struck bare bone, or rather seemed to pass into a chasm, with 
bare, rough, not crumbly bone, on every side. It was now pointed out to 
him that he had better make up his mind to the operation and come into 
the house for that purpose ; to all this he agreed, but he could not be 
taken in ; the following week the strapping was discontinued, but the 
starting-pains recurred with so much violence that his health began to suf- 
fer, and it was reapplied. 

May 22d — He came into the house, under my care, by the kind courtesy 
of Mr. Canton, and on 

May 26th. — I excised the joint. ' 

Examination of Joint. — The synovial membrane was lined, and the sub- 
synovial tissues thickened by remarkably soft, yellowish-jelly ; on neither 
humerus, ulna, nor radius was there the slightest trace of cartilage ; the 
cancelli upon the first and last of these bones lay bare, except that a soft, 
pulpy tissue seemed to grow out of them. The cancelli of the humerus 
were not bare, but a hole, about the size of the bulb of an ordinary probe, 
in the centre of the surface, led to a cavity in the bone that was filled with 
pus. 

The man has done extremely well. 
_ Case XXXVH.— On February 10, 1880, I was asked by Mr. Hird to see 
with him a boy under his care with strumous joint disease. I learnt that 
he had, at the end of 1879, first noticed a painless swelling of the joint, for 
which he could not account ; after a fortnight movement became painful 
and he limped. Eest relieved both pain and swelling, but they returned 
on resuming movement ; since the end of November the swelling has been 
rapid. He had been in hospital since January 8th, and on February 19th, 
up to which time no marked change, but perhaps some gradual enlargement 
had taken place ; he showed signs of failing health ; temperature : morning 
99°, evening 100.2°. This condition increased, the knee enlarged greatly, 
became very painful, starting-pains and loss of flesh set in. On the 8th, 
temperature, morning 98°, evening 101.5°. 

When I saw him with my colleague, I found him very cachectic, pale, 
with small weak pulse, and marks of suffering in facial expression. The 
knee was very shapeless and large, a sense of fluctuation all over it, but 
most of this was false ; some real sense of fluid was verified on the outer 



1 For the rest of this case see Excision. 



STRUMOUS SYNOVITIS. 137 

side. The question being one of endeavoring by some more active surgery 
to save, or of removing the joint, we agreed to give him the benefit of wide 
and deep incisions. 

February 12th. — Mr. Hird made a cut on each side into the cavity, from 
the inner ; no pus came, but a quantity of jelly-like granulation-tissue lay 
agape in the wound. On the inner side there was an abscess which separated 
the skin for a large distance from the same sort of tissue, but not in the 
same state ; portions of it broke away on examination with the finger, and 
little lumps, from the size of a pea to that of a walnut, came away. Another 
opening in the most dependent part of this abscess was practised. All this 
was done, and the boy was dressed antiseptically. 

February 25th. — For five days the discharge was considerable, and the 
temperature still very uneven. After that improvement became manifest, 
and on the above date the suppuration was very slight, and the thermometer 
stood morning and evening at 99°. 

March 4th. — Antiseptics discontinued ; dressed with boracic lint. 

April 3d. — Merely slow healing of the wounds to report ; the knee at 
the above date was of course still enlarged, but the tumefaction was hard ; 
slight movement only remained, the Maclntyre was taken off, and a gutta- 
percha splint substituted ; he was to get up. 

June 14th. — The boy has gone on very well indeed ; at the above date 
the wounds had all healed, and the knee was barely swollen, but was heal- 
ing by false anchylosis. 



CHAPTER VI. 

SUBACUTE RHEUMATIC SYNOVITIS. 

Acute rheumatism leaves not unfrequently a chronic painful condition, 
of joints that might be named as above ; but in such cases the peri-articular 
tissues and ligaments are more especially implicated, it is rather an arthritis 
than a synovitis, and the disease is poly-articular. The malady which in 
this chapter comes under our observation is, on the contrary, mon-articular, 
and, although it may sometimes be traced back to acute rheumatism, does 
not stand in direct continuity with such an attack, but begins some time 
afterward ; more usually it arises in a rheumatic habit through some acci- 
dental exposure, perhaps combined with traumatism, and occasionally, 
though rarely, has poly-arthritic prodromata. It is more usual among the 
richer than the poorer classes, and far more common at the knee than else- 
where. It has two forms very similar in their early, widely divergent in 
in their later, phases ; the one approaching common acute synovitis, of a 
dry or fibrinous character ; the other tending to the development of den- 
dritic or hirsute growths, from the inner surface of the membrane, thus hav- 
ing resemblance to hydarthrus, or the production of false bodies. Although 
I have rarely seen either of these diseases as a direct sequel of acuta rheu- 
matism, yet, as they are certaintly part of the rheumatic diathesis, it will be 
well to consider the phenomena of that, at present little-understood con- 
dition. 

Acute rheumatism is a systemic fever, therefore it lies, although parts 
of the body essentially surgical are affected, within the jurisdiction of the 
physician. Yet it is necessary that as surgeons we should, in order to 
elucidate the rheumatic form of joint disease, glance at the phenomena 
of the rheumatic fever, and elucidate, if not its pathology, at least its 
effects. 

The order in which the symptoms of acute rheumatism occur is not 
always the same, but whatever it be they are generally preceded by a cer- 
tain feeling of malaise and vague wandering pains in the limbs, such as are 
usual before the actual invasion of any febrile disease. After a certain 
period of this incubation there comes on a shivering fit, accompanied or 
followed by great pyrexia, indicated by a temperature of 100-103° Fahren- 
heit, acid perspirations, and by the whole train of symptoms constituting 
the perfect disease, a great part of which is pain and swelling in one or 
more joints. The affected articulations are very painful, enlarged, hot, red, 
and, when first swollen, fluctuating ; but the most remarkable feature of 
their condition is^ that a joint thus suffering, and exquisitely painful, shall 
in a few hours lose these signs of inflammation, which are transferred to 
. another and distant part. 

A very important character of the malady is the tendency exhibited by 
internal and vital organs to assume an inflammatory condition, thus, the 



SUBACUTE RHEUMATIC SYNOVITIS. 139 

peri- and endocardium, the cerebral meninges, the pleurae, peritoneum, ' 
become involved ; moreover, in the larger number of instances the inflamma- 
tion proceeds rapidly to the deposition of lymph, producing thickening 
adhesion, or consolidation, as the case may be. 

After a time, less definite than in continued fevers, or in the exanthemata, 
this malady has a tendency to get well ; this does not mean, however, 
that the patient gets well — for serious heart, or other mischief may have 
been produced — but that the pyrexia has a great tendency to decline and 
cease. The joints which were affected still remain for a few weeks painful, 
and enfeebled with stretched ligaments and relaxed membranes ; sometimes 
with damaged cartilages, and restricted motion. The patient may, however, 
die of the fever, 1 that is apparently of the intensity, or the amount of the 
pyrogenous poison, of hyper-pyrexia, and singular to relate when this usually 
fatal rise of temperature (106° to 110°) takes place the hitherto exquisitely 
painful joints cease to be tender, and generally are less swollen. 3 

Thirty years ago, Dr. Todd, insisting with much eloquence on a theory 
primarily advanced by Dr. Prout, impressed generally on the profession the 
idea that the poison, producing these very remarkable phenomena, was 
lactic acid. Dr. Fuller followed the same course. In the first edition of 
this work (1860) I showed on what very faulty chemistry this idea was 
founded. At the present day the whole lactic acid theory is abandoned, I 
believe, by all pathologists ; and indeed it is wiser to have no theory of the 
rheumatic poison. It may be said that we know as little of the poison of 
small-pox, measles, enteric fever, etc., but there is here a difference : each 
of these fevers is communicable from an infected person to a healthy one, 
each attack is the direct offspring of a previous illness — the malady being 
never generated de novo — there is evidently here something in the nature 
of organic or cell-germination. The germ or spore whose pullulation in 
the body produced the disease exhausts, in nearly all such maladies, the 
particular material on which it fed, so that an attack, say of scarlatina or 
small-pox, confers an immunity, is a safeguard against another attack. 

Rheumatic fever is not the child of a previous rheumatic fever in an- 
other individual ; it is generated each time de novo within the system of 
the sufferer. The tendency to it is in a considerable degree hereditary ; 
one attack, far from giving a certain immunity for the future, appears to 
leave behind it a predilection to renewed onsets of the disease. Proneness 
to acute rheumatism is a youthful condition ; the disease is rare as a first 
attack in a person over forty. All these peculiarities lead to the conclusion 
that faulty assimilation (primary or secondary) has produced, or that ineffi- 
cient excretion has failed to eliminate a materies morbi, whose rapid accumu- 
lation in the blood sets up the train of phenomena above briefly sketched, 
and whose slower imbibition gives rise to chronic articular rheumatism. . 
Yet what that material is remains one of nature's secrets, and herein the 
disease differs essentially from another malady of similar generation — 
namely, gout, whose specific poison is so well known and so easily demon- 
strated. 

Whatever the poison may be, it has, besides its pyrogenous qualities, 
the power of rendering the resultant inflammations very reluctant to end in 

1 The serous membranes and vascular cavities originate, like the joints, in the meso- 
blast, see p. 15. 

' The cardiac, pleuritic, or meningitic complication may of course prove fatal ; such 
patients die of chest or head mischief respectively, not of the fever. 

3 The reader should consult Dr. Pollock's excellent and very readable Notes on 
Rheumatism. 



140 DISEASES OF THE JOINTS. 

suppuration, but very prone to terminate in fibrinous thickening with ad- 
hesions of opposed surfaces, as of pericardium or pleura, or at least rough- 
ness and fibrinous vegetation of those membranes. 

Moreover, the inflammations have a quite remarkable attraction to 
fibrous tissues. Fasciae, pericardium, pleurae, are all examples of this kind 
of tissue, and are all especially open to rheumatic attacks : while post-mor- 
tem observation shows that the parts around joints, the subsynovial and 
ligamentous tissues, and the sheaths of tendons, are more often and more 
deeply affected by acute articular rheumatism than the synovial or bony 
tissues. 1 Moreover, although during acute rheumatism any considerable 
thickening of the synovial membrane is unusual, yet the increased fluid is 
often turbid, with cell-growth, and in no other inflammation are floating 
flocculi or fibrous concreta so largely and invariably found. 

Chronic or subacute rheumatic synovitis differs from acute articular 
rheumatism in some important particulars besides mere severity. The 
malady may be a relic of an acute attack, or may be ab initio a chronic dis- 
ease, without assignable local cause, or even may result from traumatism 
occurring in one of rheumatic diathesis. ■ 

This form of synovitis is generally mon-articular ; but if it have origin- 
ated in acute rheumatism, two or even more joints may be affected. 2 Occa- 
sionally, though rarely, a rheumatic synovitis of the primarily subacute ' 
variety affects two joints ; but if the disease arise in traumatism, for in- 
stance in a sprain or bruise, one articulation only is diseased. An injury 
even, though slight, if it be followed by exposure to cold, may induce 
severe affection of this description. The malady is then wont to commence 
as an acute synovitis, in which pain is strongly marked in proportion to the 
comparatively slight swelling. After a time the fluid-effusion and fluctua- 
tion subside, leaving a peculiarly shaped, hard and painful tumefaction, 
which, to the great disappointment of both surgeon and patient, proves 
somewhat obstinate. 

Inflammation is the same process, whatever its predisposing and imme- 
diate cause may be ; cell-emigration and proliferation are of necessity in 
such condition ; it is the after-history of the cell-progeny which locally dif- 
ferentiates one sort of disease from the other. In the form of synovitis 
which I have called strumous, the growth has but the very smallest ten- 
dency to form tissue, it remains simply as a mass of cells ; in the rheumatic 
disease, the impulse is always to tissue-production. The inflammatory neo- 
plasm remains but a very short time in the form of granulation, but quickly 
becomes a coarse and a rather hard fibrous structure. 

The first acute and each subsequent attack of inflammation consist, as 
all inflammations of connective tissues do consist, 3 of plentiful granulation, 

1 Dr. Todd (on Gout arid Rheumatism, p. 134 et seq.) endeavored to show that the 
articular affections of acute rheumatism are not '* true " or '' ordinary " inflammation. 
Tn my first edition I refuted this view. At the present day such contradiction is hardly 
necessary. 

2 1 have seen three cases in which three, three and a half, and five months after 
the acute disease, two joints in the first two cases, three in the last were still affected 
with synovitis, much stiffened and often very painful ; the last case might perhapa 
with propriety be termed a case of incomplete recovery ; the young lady's heart was 
considerably damaged, and much debility remained ; after some months she became 
hetter, and went by my advice to Kreuznach, deriving further advantage. In 1874, 
another attack of acute rheumatism occurring seven years after the primary one, 
proved fat 1 by severe cardiac complication and hyperpyrexia. 

3 See previous chapter, and my paper On Granulation as it Affects the Joints, in 
Beale's Archives, November, 1859. 



SUBACUTE KHEUMATIC SYNOVITIS. 141 

i.e., growth of cells. In the rheumatic inflammations the tendency of this 
growth is always fibrogenous — organizing ; hence the inflammatory pro- 
duct, or thickening, instead of remaining in the soft gelatinous stage of 
fungoid granulation, becomes a tough, firm membrane. Thus the tissue 
never reaches a rank luxuriousness of growth, since most of the cells, 
instead of generating new cells, become transformed into fibres, and those 
fibres contract. The inner surface of the synovial membrane is therefore 
hard ; presents long, rounded undulations, which run in a direction round 
the joint, and are separated often by rather deep but narrow fissures ; the 
color of the tissue is of a light red-brown, about the hue of calf leather. 
The dendritic growths of the villi encroaching on the cartilages are con- 
spicuously absent ; instead of them, thickened folds or waves of fibre-tissue 
overlie those parts which are out of contact with the opposite cartilage. The 
section is evidently fibrous, an appearance more easily visible when the 
tough tissue is torn asunder, not cut. This material occupies the place of 
the synovial membrane, that fine fabric having disappeared in the much 
coarser substance, which is formed around it and on its surface. The growth 
may be of variable thickness in different cases, indeed in different parts of 
the joint and in the same case. Thus, at the knee, it will be usually pretty 
well developed on each side of the ligamentum patellae, will be thinner at 
the back, but in the subcrureal sac is formed into a dense hard cushion, 
which not uncommonly almost fills up that space, and sometimes does so 
altogether. 

If a thin section of the material be made, and be placed, without much 
disturbance and no tearing, under the microscope, it will appear at first 
sight to consist entirely of fibre-cells, of fusiform oval and round cells, very 
closely packed together ; a more minute examination will show that the oval 
and round cells are, except on the surface or new parts, small in number, 
and that the tissue also contains a great number of fibres, which cross each 
other in every direction, and give a strongly striated and cross-barred look 
to the section, at the edge of which the fibres, projecting beyond the limits, 
are very visible. On examining, instead of a section, a shred, which has 
been torn with needles, the fibres appear more or less separate, and may be 
seen to be long cell-fibres, in many of which the nuclei are still perfectly 
distinct. The loose oval and the few round cells have almost disappeared 
in the tearing, and uncover certain torn portions of a homogeneous mem- 
brane, which evidently, in its uninjured state, permeated the whole tissue — 
Kittsubstanz. 

Some difference in these appearances will be observed, according as the 
examination is made upon a part, which has for some time been in a quies- 
cent state, or upon one which has recently been inflamed ; in the former, 
we shall find simply the elements of condensed areolar or of' scar-tissue, in 
the latter event we find such parts softened and rarefied, permeated and 
infiltrated by a fresh production of round and ovoid cells. But even in 
the very act of inflammation, the new growth is much slower in proportion 
to its greater condensation than the exuberant increase of the fungating 
synovitis. 

In all cases the joint contains a slightly increased amount of fluid, often 
rendered opalescent, or even milky by the admixture of white round cells. 
Many of these bodies are derived from the inner surface of the membrane, 
and also emigrate directly from its vessels ; others emanate from the pro- 
liferating cartilage-cells. In most cases the joint fluid is very markedly 
mixed with fibrin, much of which coagulates into transparent jelly-like 
concreta, or if mingled with cells into white opaque flocculi, looking like 



142 DISEASES OP THE JOINTS. 

soaked pieces of floating cotton-wool. I have twice found the synovia very 
thick, almost gelatinous, only a little less -viscous than that, which is evac- 
uated by puncture from a chronic ganglion. 

The ligaments present peculiar appearances, combined of thickening 
retraction and relaxation. The first is produced by an interstitial change 
in each fibre, whereby their flexibility is impaired ; hence, where by posi- 
tion the points of insertion were approximated, the shortened ligament is 
unyielding ; where separated, the lengthened tissue will not adapt itself to 
a new position. Hence considerable and painful stiffness is an early conse- 
quence of rheumatic synovitis. 

I have but once found abscesses in the thickened peri- articular tissues, 
never in the sheaths of tendons, nor among the deep muscles. When the 
tendinous sheaths are affected, they are either distended with serous or 
synovia-like fluid, or, in older cases and a more chronic stage, are thick- 
ened and partly filled with fibrous material. This peculiarity of the rheu- 
matic inflammation not to suppurate is a mere corollary of the law, that 
such an inflammation tends to fibrinate, for the cell cannot fulfil two desti- 
nies — the formation of the fibres and that of pus ; and as in these cases 
they are employed in the production of tough compact tissue, they cannot 
at the same time generate the lowly organized and vegetative pus-cell. 

The cartilages in their turn become inflamed, and exhibit in some parts 
a superabundant cell-growth, beginning at the free surface and ending in 
ulceration through the thickness of the structure : the ulcers thus formed 
are generally clothed at the bottom and sides with fibres, resulting from 
the splitting up of the hyaline substance. In other parts, and sometimes 
close to such an ulcer, a surface of polished bone will be found on a level 
with the rest of the cartilage, and therefore of course projecting beyond 
the articular osseous surface. There is no doubt that this bone is formed 
from the cartilage. I have never found such ossification of articular carti- 
lage except in rheumatic disease, and it is another instance of the organiz- 
ing tendency of that form of inflammation. 

In other cases we find these structures lose their peculiar white opales- 
cence or bluish appearance, and become of a lightish brown color, abnor- 
mally transparent, and at the same time very thin. This change is also 
due to an ossifying process, more evenly distributed ; to one which, instead 
of being confined to a small spot here and there, is distributed over the 
whole or a great part of the articular surface of the bone, and causes a grad- 
ual encroachment of the osseous upon the cartilaginous structures. This 
mode of action is peculiar to the more chronic forms of the disease. 

In more rapid cases, in which the ulceration of cartilage and the local- 
ized spots of ossification appear, it is not unfrequent to find parts of the 
cartilage with its articular lamella detached from the bqne. In a case 
which was to me of extreme interest, all these three conditions were pres- 
ent. In other cases only the gradual thinning of the cartilage and some 
ulcers apparently old are found. 

The bone is found nearly always condensed, i.e., the walls of the cancelli 
thickened, and each cavity proportionally diminished in size, the whole 
therefore heavier and more solid (osteosclerosis). This is often strongly 
marked in the portion next the articular lamella, where the bone becomes 
much condensed. Besides this, the inflammation, as it spreads from the 
synovial, affects the fibrous tissues, viz., the periosteum, and others lying 
close to the bone ; the inflammatory products which these "throw out do 
not stop in the condition of granulations, nor do they suppurate, but ad- 
vance rapidly to ossification, thus producing thickening, and, as much of 



SUBACUTE RHEUMATIC SYNOVITIS. 143 

the new material is in irregular masses, the so-called osteophytes. Such 
growths are rare in strumous synovitis, and when they do occur are com- 
paratively rather small and unimportant. In strumous ostitis they repre- 
sent mere roughnesses, overlapping carious depressions. In rheumatic 
synovitis they take a more important place ; yet do not attain that stalac- 
tite form of exuberant growth which is seen in arthritis deformans. Never- 
theless, though small and generally conical, they are numerous, and fre- 
quently occupy a large extent of the surface, spreading to a considerable 
distance from the joint. 

When the cartilages have become more or less destroyed or ossified, 
the bones of the joint begin to grow together, and in this process again the 
organizing character of the disease is manifest. When we look at a joint 
anchylosed by this form of synovitis we find that the junction is produced 
by considerable addition ; generally the patella unites first to the outer 
condyle of the femur by an osseous stalk that seems to grow from both 
bones ; then the femur and tibia become joined, also by processes, that 
arise from the two condyles of the former and articular surface of the lafr 
ter ; the inter-eondyloid notch- may remain open and form a foramen run- 
ning through the middle of the conjoined bones. I believe this sort of 
junction to be assisted by adhesion to the bones and subsequent ossifica- 
tion of the menisci. This mode of bony anchylosis is very different to the 
strumous in which the two bones seem to sink into one another and to 
unite by fusion, instead of, as in these cases, being glued together by a 
thick lump of cement, which afterward becomes osseous. 

There is a peculiar look about bones in this state ; the natural eleva- 
tions and depressions become exaggerated, the surface here and there 
roughened by an osteophyte ; the openings, whereby little arterial twigs 
find their way into the inside of the spongy tissue, and which are normally 
very small, become plainly visible holes and grooves. In fact, the bones, 
without being very perceptibly increased in size, are exaggerated ; as it 
were, caricatured. If a bone-end in the earlier phases of the disease be 
split, the cancellous structure appears throughout redder than natural, and 
the cancellar walls are hardly visible, being concealed by the bulging out 
of the enlarged contents. Afterward, patches of, and later still, all the, 
section are found to be whiter and paler than the norm, from thickening 
of the lamellae and consequent diminution of the cavities (osteo-sclerosis). 1 
This osseous induration is generally most marked in the part that lies next 
the articular lamella. In some cases the cartilage and the articular lamella 
are here and there ulcerated through ; the cavity of the ulcer is cut off from 
the rest of the articular facets by a ring of ossified cartilage : in other cases, 
and in other parts of the same case, a great portion of the deep surface of 
the cartilage is ossified ; here the articular lamella has to a great degree 
lost its peculiarity of possessing no lacunae with canaliculi ; many of the 
black undeveloped bone-cells have thrown out such prolongations, and the 
structure assumes more and more the ordinary characteristic of bone-tissue ; 
until, in the furthest advanced parts — those where the whole thickness of 
the articular cartilage is ossified — the structure becomes ordinary bone. 
The process is another instance of the organizing quality of this sort of in- 
flammation. I have never found in any other form of synovitis the black 
corpuscles of the articular lamella throwing out canaliculi. If such an 
altered spot be, as sometimes happens, opposite a piece of the other bone 
as yet covered by cartilage, normal or ossified, and if motion be still allowed, 

1 For fuller particulars of this process see Chapter XI. 



144 DISEASES OP THE JOINTS. 

its surface becomes polished and smooth as glass ; but if the spot be op- 
posed to a part on the other bone similarly circumstanced, and motion be 
prevented, the two grow together by the formation of new bone between 
them. It thus occasionally happens that a patch of cartilage and a cavity 
lie in the midst of this sort of anchylosis ; the cavity may contain opales- 
cent or puriform fluid. I do not know how long such reliquiae of the joint 
sac may persist. 

The other form of rheumatic synovitis is less fibrogenous ; it is charac- 
terized by less thickening, a greater amount of fluid effusion, and consider- 
able enlargement of the synovial fringes. The thickening, though less in 
amount, is remarkably tough ; its section is often of a bluish color like 
tendon — probably not throughout unless the case be very far advanced ; 
but only in longer or shorter lines, according to the age of the disease ; if 
such a joint be opened under water, a number of arborescent growths will 
be seen sprouting from certain parts of its inner surface. These are most 
abundant about the folds ; indeed, wherever fringes normally exist, but in 
advanced conditions of disease, a few may spring from parts which are not 
naturally provided with these appendages, as. for instance from the crucial 
ligaments of the knee. When the shoulder is the seat of disease, hyper- 
trophied fringes have a remarkable predilection for the fold of membrane 
covering the biceps tendon. These growths are papillomatous in appear- 
ance, like that form of growth of the bladder or a cluster of villi from the 
chorion, but ihe ends of many of the twigs are bulbous, and some have a 
distinct knob containing a little bead of fibrous tissue, or of cartilage, some- 
times only a cell or two of cartilage, surrounded by an obscurely fibrillated 
matrix. In these particulars, the malady is like the commencement of 
hydarthrosis with dendritic growth, but the growths are smaller and less 
numerous ; yet no doubt one disease may merge into or become the other ; 
nor shall I attempt to draw a sharp line of distinction, which I do not 
believe to exist. The malady may, as just stated, end in a hydarthrosis — 
it may be cured, or on the other hand it may put on all the characters of 
the more acute synovitis formerly described. 

The joint contains a very variable quantity of fluid, but its looseness (i.e., 
abnormal mobility) is considerable in proportion to the amount of effusion ; 
the ligaments are much affected, their fibres intermixed with new inflamma- 
tory tissue, which lies looser and less firmly to the bones, although inter- 
stitially condensed. 

Symptoms. — This malady, as it usually arises from a more or less acute 
attack, has generally a definite pedigree, be it a rheumatic fever, a certain 
injury, a well-remembered exposure to cold, or both these latter combined. 1 
If the case originate in acute rheumatism the condition is sufficiently clear, 
without further comment on my part ; if it spring from the last set of 
causes the narrative runs somewhat in this wise : after the accident or 
chill or both, the joint was swollen and painful, it was treated, and after a 
time got well, or so nearly well, that further surgical aid was discontinued, 
and the remaining stiffness was expected to subside ; yet the discomfort 
never entirely disappeared, the patient on rising felt the joint stiff (it is 
most commonly the knee or shoulder), found that straightening it was 
painful or impossible, and that on first attempting to walk he could not, at 

1 I have found that among my private cases a goodly proportion are due to fishing, 
i.e.. standing without waterproofs in the river, or getting beyond the depth of the fish- 
ing-stockings ; also to slight injuries while hunting or shooting, followed by getting 
wet or thoroughly chilled. A case at the end of this chapter is typical of this mode of 
commencement. 



SUBACUTE RHEUMATIC SYNOVITIS. 145 

all events without considerable pain, put the heel to the ground, 1 it may be 
that this continued discomfort is severe and lasting enough to cause ths 
sufferer again to seek advice, or he may trust to its subsidence, or again it 
may really very considerably abate. Even in this last event the patient is 
conscious of a variable degree of stiffness and difficulty of certain move- 
ments in the morning, and though after some exercise these symptoms will 
disappear, yet it is precisely on the morning after a day of considerable 
exercise, when the joint appeared most free, that an increased amount of 
inconvenience is felt. Also, after some unusual exertion, a little over-fatigue 
or over-work, mental or bodily, perhaps after some error in diet, or slight 
depression of health, the limb instead of feeling well, or nearly so, seems 
both stiff and heavy. Generally, too, under such circumstances vague and 
uncertain pains will be felt in other joint* of the same limb, or if the dia- 
thesis be strongly marked also in distant joints, between the scapulae, or in 
the spine. Soon the peculiar stiffness, at first only noticeable after rest in 
bed, will also, be felt after sitting down for a few minutes or keeping the 
joint in flexion for half an hour or so. Afterward the limb becomes ob- 
scurely painful during rest in bed ; there is difficulty in finding a comfort- 
able position, and the same posture will not be comfortable for long ; soon 
afterward there comes on a tendency to cramp in the flexor muscles, and if 
the patient feel them with his hand, even when not cramped, but merely 
aching, he finds them stiffened and hard ; more especially if the affection 
be at the knee, is the biceps contracted, and often painful. At this period 
the joint itself will not be much swollen— occasionally a little increase of 
fluid may be found, there is no tenderness on pressure ; but movement, es- 
pecially after long quietude, causes crackling — very fine in some cases, in 
others coarser. Imprudences in diet (in what is drunk, rather than in what 
is eaten), changes of weather, getting wet, being insufficiently guarded 
against unexpected cold, over-fatigue, mental or bodily, exacerbate the 
trouble, which rarely in this nascent state advances gradatim, but by inter- 
vals of ease and periods of pain. 

At last the patient is conscious that the attacks are longer and more se- 
vere, while the intervals are shorter and even less free than before, and he 
begins to think the joint is getting worse ; he may more especially be sure 
of this, if the extensor muscles on the upper, and some muscles of the lower 
segment participate, as, is usual at this stage, in the discomfort ; and if, as 
is even more common, the limb begin to waste. 

Now if surgical advice be sought the patient will be found not ill ; but 
not quite well — there is a sense of irritability. The tongue is rather white 
and marked at the edge by the teeth — bowels inclined to be irregular, some- 
times constipated, sometimes the reverse — the urine very acid, depositing 
lithate of ammonia in abundance, or not unfrequently, the cayenne-pepper - 
like lithic acid. The breath has a faint and sour odor, chiefly detectable in 
the morning before taking food, and some patients even volunteer, that 
ihey have an acid taste in the mouth ; these last symptoms, especially the 
matutinal acidity of the breath, are most marked in those who take too 
much stimulant, even though far short of what is usually called excess ; 
but it is occasionally observed in those who are abstemious, or are even 
total abstainers. 

Each of the attacks will leave additional thickening of the synovial mem- 

' If the shoulder be affected lifting the arm sideways, if the elbow, outward rotation 
of the hand, if the wrist, rotation outward and extension are the painful movements. 
The hip is most sensitive to abduction and rotation outward, the ankle to extension. 



146 DISEASES OP THE JOINTS. 

"brane and peri-synovial tissues, as also more narrow limits to movement. 
In the first few exacerbations, the shape and appearance of the joint re- 
semble that of subacute sero-synovitis ; it is rounded and fluctuates, after- 
ward the condition assumes the characters of old disease, in that the normal 
form of the sac caricatured by distention (see p. 32) is now changed. It is 
of a square, angular character, which is very distinctive ; the outlines of the 
swelling tend to the straight, and the edge of the tumefaction, felt on tra- 
cing the contour of the limb downward with the hand, is clear and defined. 
This shape appears to me due to the contracting nature of the fibrous ma- 
terial, which, being toward the centre, draws the subcutaneous tissues and 
the skin itself inward. The tumefaction is hard, elastic, in most parts 
leathery, and, unless the cavity Tje full of fluid, there is no sense of fluctu- 
ation over the joint as a whole ; and even in this contingency the wave is 
felt to be separated from the finger by a dense tissue. The bursiform pro- 
longations of the synovial sac are favorite seats for formation of fibrous tis- 
sue, and thus in the knee the subcrureal sac, in the elbow the pouch beneath 
the anconeus and triceps feel hard and lump-like, very much like additions 
to the lower part of the muscles, or like pads of india-rubber. In old cases 
the fluid will, in one or perhaps two places, approach nearer the surface, 
the wall having become thinner in this situation, where it fluctuates, feeling 
not unlike a deep abscess. 

After a time, starting pains will be added to the other distresses, and 
these are more violent than is usual at this stage of the strumous form of 
malady. I have seen a poor fellow start up and seize the knee in a sort of 
fury, grind his teeth in agony, and break out in a clammy perspiration ; 
but this case exhibited them in an unusually violent manner. The limb, 
already much thinner than the other, begins now to waste very rapidly and 
remarkably ; the muscles, particularly the flexors, get thin, while they re- 
main contracted, feeling tight and sharp, like cords beneath the skin. Ten- 
derness of the joint-surfaces is not usual, and when it comes on lasts only 
a little time ; on the other hand, bony grating is common, and often con- 
tinues to the end of the case. The heat of the part is greater than the 
slowness of the inflammation would warrant us in expecting ; it is not of 
course equal to that of acute rheumatism, but is more than in any other 
form of chronic synovitis and considerably above that of the fellow-joint. 

The redness is in the first few attacks well-marked, afterward less so, 
probably on account of the greater thickness of parts ; but in the continu- 
ous inflammation, which always comes on unless the malady be cured, the 
hue of the joint is deeper, and of a browner tint than the rest of the skin. 
The brownish hue which may have been imparted by the action of blisters 
is not, however, to be mistaken for a morbid symptom. 

The joint is not unfrequently movable in an abnormal direction ; the 
tibia may be pushed back, even from side to side, or the ulna may be moved 
laterally over the humerus. This is sometimes accompanied by very severe 
pain and violent spasmodic contraction of the muscles, setting the limb fast 
until the bones are replaced ; sometimes, on the contrary, no pain is pro- 
duced. The abnormal .movements are always attended by a peculiar hard 
grating, harder but less rough than the crepitus of fracture. 

The sheaths of tendons, as for instance of the ham-strings, if the malady 
be situated in the knee, may generally be found, in advanced cases, thick- 
ened and enlarged, as well as hard from retraction of the contents. 

It is worthy of notice, that as the constitution fails in strumous cases, 
the lungs and brain are extremely apt to suffer from a rather rapid form of 
tuberculosis. In rheumatic cases the former organs incline to be affected 



STJB ACUTE RHEUMATIC SYNOVITIS. 147 

■with a peculiar dry form of bronchitis : there is expectoration, in the morn- 
ing, of little hard lumps of mucus, more or less dark in color, and the 
bronchial sounds are harsh and whistling ; the mucous membrane of the 
tubes is thickened. The heart, in one case that I saw, was slightly diseased ; 
there was a rough sound on the systole ; how long this had been present 
could not be determined, but it increased perceptibly as the case went on. 
Such an addition to the disease is, however, a concomitant, brought on 
either by previous acute rheumatism or by the general diathesis, and though 
not, of course, immediately connected with the joint-affection, either as 
cause or effect, should always be looked for. 

The dendritic form of rheumatic synovitis is in its symptoms entirely 
different. It has, as a rule, no clear history or genesis, but commences 
gradually, the patient scarce knows when or how. The pain is slight, be- 
ing rather a sense of weakness, distention, and unreliability, except after 
some prolonged exercise or over-fatigue ; therefore, on rising in the morn- 
ing, the limb is at "ease. Occasionally, in walking the patient feels a sharp 
stab of pain, which may last a considerable time, or in other cases is more 
transitory. The joint is more rounded than in the other form of rheumatic 
malady, less so than in acute synovitis. Examination will detect fluctuation 
and if, on the most accessible parts of the synovial membrane, as on either 
side of the patella, or at the back of the elbow, pressure with the finger be 
made, and the soft parts be moved backward and forward over the bone, crepi- 
tation larger or smaller will be felt. This lies sufficiently distant to make it 
plain that the roughness is not subcutaneous. Moreover, if the surgeon grasp 
the joint firmly in two hands, with the palms and fingers, so as to get as 
much sensitive surface next the articulation as he can, he will feel, as the pa- 
tient alternately straightens and bends the limb, a peculiar crackling. This 
sensation is entirely different to that of bony crepitus, or even to the softer 
crepitus of cartilage in a state of ulceration. I can compare it to nothing 
better than to a tangible rustle of silk. If a piece of stout and stiff silk be 
folded between the finger and thumb, so that two surfaces are in contact, 
and if these be rubbed together, the sort of, friction conveys to the hand a 
sense exactly like this particular crepitus. In such an articulation careful 
palpation will often detect little lumps or nodules evidently in the joint 
cavity, which move and glide away when pressed upon ; there may be many 
of these, or only one or two, they do not glide far, but can easily be found 
again in the neighborhood. Sometimes pressure in this way gives to the 
patient an uneasy sensation. After a time abnormal mobility is very com- 
mon ; for instance, in the extended posture of the knee, one may bend out- 
ward or abduct the tibia on the femur, and on restoring normal position, 
the inner tuberosity may be felt to knock against the condyle, like the lid 
of a box sharply closed. 1 

If cases of this sort get worse they tend in two directions, either to the 
production of pendulous false bodies within the joint and to the develop- 
ment of cartilaginous plates or fibro-cartilaginous thickening of the synovial 
membrane (which forms of disease are fully discussed in Chapter VII.), or 
to further distention and enlargement of the synovial cavity, leading to one 
form of hydrops articuli, also the subject of a special chapter. 

Treatment. — Although the immediate cause of this malady may be trau- 
matism, yet its persistence or recurrence depends upon a diathesis ; we 
have, therefore, to do with both constitutional and local treatment, and 
with each during the attack and during the remission. 



' This symptom ponnecta tv "> ^" a ° f,1r ""' lTr " rith TT-irHnrfrhrosis, Chapter VIIL 



148 DISEASES OF THE JOINTS. 

Treatment during the Attack ; General. — All inflammations tending to 
fibrinous development of their products are more especially those that de- 
rive benefit from two remedies, namely, mercury and iodine. The former, 
however, must be very carefully employed, in small doses, not long con- 
tinued, and even thus only in sthenic constitutions, uninjured by age, in- 
temperance, or other depressant. In such case it may be given by the 
mouth, or by the skin of the inflamed joint. This latter method will have 
to be referred to again ; and as it is valuable, .the surgeon should remember 
that he may deprive himself of this resource if the mineral be otherwise 
administered. Should it be determined to use mercury internally, the most 
commendable forms are soluble ; partly because sufficient effect can be at- 
tained with much smaller quantities of the drug, partly because we know 
really what doses are taken into the system, which we can never estimate 
with the solid forms. Moreover, when we stop the administration, absorption 
ceases, which is not the case when about the intestinal folds and villi por- 
tions of the insoluble protoxide or chloride may remain hanging. I prefer, 
therefore, the perchloric! e or the biniodide (Formulae X. and XI. ), or a larger 
quantity of iodine may be given in the combination. Two precautions in 
regard to this drug are to be observed : it should never be allowed to affect 
the gums, or even the breath ; it should not be used while there is pyrexia, 
not even when the evening rise of temperature exceeds the norm by more 
than a decimal or two. 

In the choice of this remedy, or if using it at all, in the period of its 
discontinuance, we may judiciously take the urine as a guide ; a large sedi- 
ment of lithate of ammonia, pretty deeply stained, does not contraindicate 
the use of mercury, although a red sand, the pure lithic acid, does, to my 
mind, form an objection ; also, if the fluid be very acid, and often in such 
urine the mere precipitation of the lithates is no proof of their excess, mer- 
cury may well be omitted, lest it take the place of other and more valuable 
remedies. Neither do I think that in such condition the action of that 
medicine is always satisfactory. 

Of iodide of potassium I sljall have to say a few words in the sequel. 
Here it is only necessary to observe, that if given during pyrexia, its possi- 
ble effect of increasing that condition must be watched, and should this fol- 
low, the drug should be discontinued. . It is most useful in the earlier 
phases of this disease, when the diathesis is strongly marked, especially 
when the synovitis is a relic of acute rheumatism. Such constitutions are 
able to bear rather large doses, the effect of which is increased by the ad- 
dition of ammonia. 

If the urine be highly acid, and be loaded with lithates, more especially 
with red gravel, this drug, combined with bicarbonate and nitrate of potash, 
or with carbonate of ammonia, rendered effervescent, if one will, with citric 
acid, is most valuable. With these may be joined, if desirable, small doses 
of colchicum. (Formula XH. o* XIII. ) 

This last, as in all cases of rheumatic synovitis in which pain is a promi- 
nent symptom, and the lithic acid diathesis strongly marked, is most valu- 
able. I have seen very severe suffering relieved by it alone. Caution must 
be employed, lest the drug cause too great depression ; for occasionally even 
small but continued doses of colchicum are followed by intermittency of the 
pulse. 

The use of opium in all rheumatic disease is well known. It acts not 
merely as a sedative or anodyne, but also as a sudorific, and appears to ren- 
der the urine less acid. From five to ten grains of Dover's powder at night 
is often very beneficial. In severe cases five grains may also be given during 



SUBACUTE RHEUMATIC SYNOVITIS. 14:9 

the day. A combination of opium -with antimony and bromide of potassium 
is frequently very beneficial. In this manner, or if the skin be dry, James's 
powder may advantageously be used; 

Within the last few years a drug has been introduced into medicine, 
whose control over rheumatism and rheumatic inflammations is very con- 
siderable. Since, in the early part of 1876, Dr. Maclagan ' published his 
cases of acute rheumatism treated by salicine, this disease has lost nearly 
half its terrors. Of its use in the fever I am not entitled to speak, but to 
its value in this form of synovitis I may testify. The special disease over 
which it has most control is rheumatic fever. Secondly, that which is left 
after such attack ; but it has marked effects in all cases of rheumatic syno- 
vitis, when there is some pyrexia (100°-102° Fahr.) and when the urine is 
markedly acid with plentiful deposit. 

More important perhaps, than any drug, is the regulation of the diet. 
While any feverish symptoms continue, and while the urine exhibits abun- 
dance of lithates, butchers' meat should be taken very sparingly, or not at 
all ; the food should be plain and simple, no pie-crust, very little sugar, and 
no beer. Sometimes we may find a difficulty in cutting off all stimulus ; 
if any be given, a little old and pure whiskey is certainly the best, if it do 
not, as sometimes happens, derange the liver ; if wine must be given, claret 
and hock are the best ; Moselle is also tolerably harmless, but port, sherry, 
champagne, and more especially burgundy, must be strictly forbidden. To 
this subject I must shortly recur. 

Treatment during the Remission ; General. — We now come face to face with 
one of the most difficult problems of our art — the endeavor not to cure a 
disease, but to change a diathesis, and it may well be asked if we can ever 
succeed ? Diathesis may be taken to mean the aggregate result of all ha- 
bitual functional aberrations, of all peculiarities in bodily acts, which in 
their entirety are simply animal life, such as assimilation of food, change of 
tissues, discharge of waste, etc. We may well ask if any drug, any mode of 
life can change the entire chemical and vital dynamics of corporeal existence. 
The reply must very jauch depend upon the circumstances producing the 
conditions in question. A certain tendency of body inherited from past 
generations, fostered perhaps by youthful, happy disregard, or, at least, 
never combated until pain assumes an imperative mood, may hardly be 
overcome, though it may be alleviated and modified. But a rheumatic 
state — a Hthic acid diathesis — in the first generation, brought on by over- 
training — frequent exposure to cold — free use of beer and sherry — bodily 
indolence, or other such cause, may certainly be eliminated, and with the 
more ease the earlier it be attacked. In this phase much the same drugs 
as in the condition just described may be used, but somewhat differently. 
Mercury only as an. alterative can be given for short periods of about a 
week, with advantage, if the bodily strength be considerable. Opium and an- 
■ tiinony are better avoided. Our sheet-anchor in the way of drugs will be 
salicylic acid or a compound, iodide of potass, potash and ammonia very 
occasionally, colchicum in alterative doses. Let it be remembered that to 
do any good these are to be taken for a long time, and we must not, there- 
fore, let the doses be large. Also much care is necessary, not too greatly to 
lower the patient, or to weaken digestive powers ; hence many of these 
medicines should be combined with a tonic. Quinine or iron may both be 
given cautiously, especially the latter, with either mercury or iodine, even 
with both ; the liquid extract of bark, gentian, and other bitters are all 

1 Lancet, March 4 and 11, 1876. 



150 DISEASES OP THE JOINTS. 

available. A potent remedy is the water of the Woodhall Spa, in Lincoln- 
shire. I shall have occasion to speak of this in the sequel. (See Chapter XI.) 
Here I will only say that properly given, and carefully watched, it is very 
valuable, and that I have found the greatest advantage from its use. 

The diet is by no means the least important part of treatment, but is 
often the most difficult. Persons with this diathesis are peculiarly liable 
to acid dyspepsia, they avoid bread, dislike puddings, either of rice, sago, or 
arrowroot, and will not touch milk ; they are almost exclusively carnivorous, 
and the stomach (which is very much a creature of habit) quarrels with 
any other food. But all this must be slowly changed, for as long as the 
urine is strongly acid and lithiferous, we must check the consumption of 
meat — at all events of the brown meats ; substitute bread-stuffs, by giving 
toasts, fried bread, eggs in various ways. To these persons some stimulant 
with food is, for a time at least, essential, since without it the contact of 
food excites in the stomach excessive secretion of acid ; this stimulus is 
generally the very worst, either sherry, champagne, or both.' 

The obstinacy of habit is often my greatest enemy. It is astonishing 
how difficult it is to convince most men that the thing they have done all 
their lives, without immediate ill-effects, while under forty, may, neverthe- 
less, be the chief cause of their woes when approaching fifty. Nevertheless, 
an entire change must gradually be brought about. I say gradually, be- 
cause I do not believe good is to be got out of any sudden and precipitate 
revolution, and because the whole round of social life, the dining ou,t, the 
interchange of hospitality, etc., etc., are all involved in the question of diet. 
Thus few people can mentally bear to have all their cherished habits al- 
tered at a moment's notice ; or to be told that what from their earliest youth 
they have believed to be the way English ladies and gentlemen ought to 
live, is for them bad and injurious. 

Perhaps no more need be said to show, that tact must be as much em- 
ployed as knowledge in managing such cases. One resource, if other 
efforts fail, will help to break down the evils of habit — a few months at a 
Continental bath : Buxton, Bath, Harrogate, and eve* the almost unknown 
Tenbury, contain waters which are, for most cases, quite as good as Kreuz- 
nach, Aix, Carlsbad, and others : but if besides the mere benefit of the 
waters, other objects are to be aimed at, no place in England (to which the 
patient will go) is so suitable as some spot abroad, thoroughly given up to 
the deity of the Brunnen, where so many minutes in the bath, and so many 
tumblers of the spring is the end and aim of the day's existence, and where 
the accustomed sherry and champagne are not the fashion. 

But there is another condition of system which is sometimes combined 
with rheumatic synovitis, namely, asthenia, and this is generally notified 
by pale urine, either very slightly acid, neutral, or in .the worst cases alka- 
line, the sediments in which are phosphatic. Here an entirely different 
system, both of diet and medication, must be pursued. Almost every drug- 
above mentioned, save salicine and the tonics, must be tabooed. Quinine, 
iron, nitric and hydrochloric acid may all in turn be exhibited. Alkalies 
act injuriously in these cases. Stimulus, even sherry and champagne, but 
more particularly the latter, may be given at meals ; while a diet more or 
less generous, according to the debility of system and alkalinity of the urine, 
should be allowed. Here then are two opposed conditions of system, and 
two entirely different methods of treatment. Let me remind my reader 



1 "The glass of sherry after my soup" is a rite very difficult to abolish, still more 
the " half glass of sherry at my club before I go home to dress for dinner." 



SUBACUTE RHEUMATIC SYNOVITIS. 151 

that what I •will here call acid rheumatism may be very disadvantageously 
changed into alkaline rheumatism, by a too long continuance of alkalies, 
and too depressant a treatment. With very much more difficulty may the 
alkaline form be reversed by over-feeding and stimulation. He who is wise 
will be wrecked neither on Scylla nor Charybdis. 

Treatment in Acute Stage ; Local. — If we have to deal with a relic of rheu- 
matic fever, we must carefully look to the posture in which the joint haa 
been allowed to rest, for, during that disease, movement may have been so 
painful as to render the physician unwilling to add to his patient's suffer- 
ings and pyrexia, by insisting on a surgically good position. 1 It may be 
that the limb is undesirably bent, or even some subluxation may have oc- 
curred. This must be rectified, a splint applied, and the already described 
conditions of skilful surgical treatment enforced. It is hardly necessary 
to say that absence of fever is presupposed ; we are not dealing with the 
latter part of acute rheumatism, but merely with a rheumatic joint. When 
a good position is attained, the inflammatory condition will sometimes al- 
most vanish of itself ; it will, at all events, have been rendered more amen- 
able to treatment. If the joint be hot, red, and tender on pressure, some 
local bloodletting, after the method already described, is often advanta- 
geous ; heat by the salt-bag is beneficial ; cold is not usually advanta- 
geous ; but when heat is disagreeable and cold grateful to the feelings, it 
may be cautiously employed. Liquid effusion into the joint-cavity is rarely 
sufficient to require puncture, but, on the other hand, the peri-articular tis- 
sues often contain fluid, as evidenced by a small amount of pitting, or at 
least whiteness of surface after pressure by the finger. In such cases the 
part may be covered with cotton-wool, over which a quantity of spirits-of- 
camphor has been poured, and allowed almost to dry ; or into which finely 
powdered camphor has been shaken, and this is to be tightly bound with a 
flannel or domett bandage. I have also applied salicylate of soda in strong 
solution, by soaking in the fluid strips of lint, with which the joint should 
be strapped, and the whole covered with one of the above-mentioned band- 
ages. 

When the severity of the inflammation has subsided, local applications 
of mercury may be used advantageously, if the drug have not been given 
by the mouth, save as a mere purgative. If the constitution be sthenic, 
and if the fluid part of the swelling have disappeared, leaving considerable 
fibrous enlargement, having a cork-like, hard feeling, the camphorated blue 
ointment, pure or mixed with an equal proportion of iodide of potass oint- 
ment spread on strips of lint, may be strapped on the joint, covered with 
thin mackintosh and a flannel bandage. The systemic effect will require 
watchfulness. The oleate of mercury, a compound introduced by Mr. Mar- 
shall, is elegant and efficacious ; moreover, the mineral may be dissolved in 
different proportions : 1 in 20, 1 in 10, and 1 in 5 of oxide of mercury, to 
the acid permitting of variations in potency of the application. About 
twenty minims is the average quantity to be painted on or lightly rubbed 
into the skin twice or at most thrice a day ; but, unless a pretty sharp pus- 
tular counter-irritation be desired, it is well to mix the solution with 
about an equal quantity of oil or of lard. I have found this preparation 
valuable when considerable thickening has been produced by the inflamma- 
tion, and believe that it acts rather more quickly than the mixture of blue 
and iodide of potass ointment, and certainly more quickly than the former 

1 After severe fevers it is very common to find the ankles much flexed — the feet in 
equinoua position. 



152 DISEASES OE THE JOINTS. 

alone. Another valuable advantage of thus employing oleic acid as a sol- 
vent, is the power it gives us of combining other drugs : thus one or two 
grains of morphia (the alkaloid) may be added to each drachm of the oleate, 
or of atropia half a grain to the drachm. These preparations are very valu- 
able even in the inflammatory stage of rheumatic synovitis, particularly if 
accompanied by considerable suffering. The morphia compound, when the 
pain is continuous or nightly, the atropia when it is more paroxysmal, and 
especially if of the starting variety, may be employed with very considera- 
ble advantage. Also, it should be said, that although as a rule I would ad- 
vise mercury, yet the combination of oleic acid with one. of the sedative 
drugs above mentioned, may be used alone, especially if little or no fluid 
be in the peri-articular tissues, if the thickening be inconsiderable but the 
pain severe. 

Or — but not in combination with the above remedy — blisters may be 
applied on those localities already specified as most available. By these 
means, in conjunction with the suitable constitutional remedies, we can 
generally subdue the immediate mere inflammation ; but if, during the fever 
and the few subsequent days, so much mischief have been done to the joint 
that we can only hope for anchylosis (true or false), we must carefully and 
sedulously watch the position of the limb, so that as soon as more quiescent 
symptoms permit, we may use some passive motion, or at least occasional 
change of position ; thus preserving as much mobility as possible within 
the range of a surgically* good posture. 

The management of cases originating in slight traumatism combined 
with chill, will first be conducted on the same principles as for simple acute 
or subacute synovitis, but on the subsidence of inflammation, and on the 
appearance of those recurrent symptoms described at p. 145, a somewhat 
modified plan is necessary, and this will depend on the amount of inflam- 
matory action still persisting. The fact that after rest there is pain, warns 
us that entire immobility may end rather rapidly perhaps, in considerable 
stiffness. Hence, even though the patient may not be allowed to walk or 
to exercise the joint, yet movement should be used according to the amount 
of pain and swelling. Shampooing, with passive motion, frequent frictions 
(often these may be self-applied) will be beneficial. If the knee be the af- 
fected joint, I often order the patient to sit on a table, attach a weight of 
two or three pounds to the foot, and swing the leg for about ten minutes 
twice daily. At night the joint may be wrapped in a flannel roller, dipped in 
a solution of bicarbonate of potash, ten or fifteen grains to the ounce, and 
this may be enveloped in thin india-rubber sheeting. If, when the patient 
gets up in the morning, there be difficulty in straightening the limb, a 
pasteboard or poro-plastic felt-splint should be moulded to it, in the 
straight or nearly straight position, and either strapped or bandaged on 
during the night. Also he must get into the habit, when sitting to write, 
read, or dine, of keeping the knee rather straight, and for this purpose a 
footstool or leg-rest may be provided. The difficulties and pains already 
described will not occur on bending the limb ; flexion is the peccant ten- 
dency. 

Should an exacerbation occur, movement must stop for a time, mercury 
locally, a blister, either a carbonate of potash bath, or compress, and entire 
rest for a few days, in a splint be . enjoined, while constitutional remedies 
are exhibited ; both local and general treatment are to be gradated on the 
severity of the attack. Frequent recurrence, each one leaving more thick- 
ening than the last, shows us that the dyscrasia is more potent than our 
remedies, and now, it may be that a retentive bandage of some light material, 



SUBACUTE KHEUMATIC SYNOVITIS. 153 

as dextrine or silicate of potash, should be applied, and the patient sent to 
Harrogate, Bath, Buxton, or to Aix, Carlsbad, Kreuznach, Vichy, as the 
case may be. If from financial or other circumstance this cannot be ac- 
complished, we must, while modifying the plan of constitutional remedies 
within the lines above specified, treat the case locally more severely, or 
change the remedies from one to another of those named. A long course 
of blisters applied alternately to different parts of the surface so that one 
is always open ; even two lines of the actual cautery, or on the other hand 
r simply long retention in an immobile apparatus (this generally connotes 
more or less anchylosis) may be the only remedy, but in my experience 
these cases are quite amenable to treatment, if the sufferers be sufficiently 
docile, and — for generally the cure will take some considerable time — if 
they do not lose patience. 

The other form of rheumatic synovitis will, unless the fluid be large in 
amount, require much the same management. When there is considerable 
effusion within the synovial membrane, the most successful treatment is to 
withdraw this with the aspirator, and immediately to strap or to bandage 
the joint with an elastic web-roller and with very considerable pressure. 
When the fluid is withdrawn crepitation is often very distinct, and little 
nodules may not unfrequently be felt. I have often found on removing, after 
a fortnight, the strapping or bandage, that both these symptoms have dis- 
appeared, and some rubbing, with passive motion, has perfected the cure. 
But for so successful a result, the case must be taken early. Blisters or 
rubefacients will after either procedure be of some avail. On two different 
occasions I, on the third time of using the aspirator, passed into the joint 
two drachms of three per cent, solution of carbolic acid ; in one of these the 
result was excellent, in the other good, not quite so perfect. If, indeed, 
the inner surface of the synovial membrane be rough and hirsute, with 
dendritic fringe-hypertrophy, I really do not see how such a case is to 
•escape constant serous effusion, and reiterated attacks of inflammation, un- 
less some such means be taken. I consider that aspiration of the cavity, 
followed by pressure, causes absorption, shrivelling, and decadence of the 
growths, while the injection probably produces the same effect by causing 
an effusion of lymph from the surface, matting the little growths together, 
and once more giving to the membrane an even if not polished surface ; 
that much of this fibrin is afterward absorbed, together with the organ- 
isms it enclosed. 

Case XXXV111. — Captain B. sent for me to see him October 4, 1876. 
During a great part of the previous year he had suffered from a severe and 
painful affection of the right knee, which under treatment in Dublin got 
well ; but almost immediately afterward the left knee became very painful 
and swollen ; the same surgeon treated him for four months, at the end of 
which time he came to London and consulted me. 

I found the knee considerably swollen and the thigh much shrunken ; 
the enlargement was hard and resilient, while on deeper pressure a sense 
of slight hypersecretion into the joint could be detected ; the shape of the 
swelling was rather square, the subcrureal sac of the synovial membrane 
was full of a deposit, feeling like fibrinous material, whose edge could be 
plainly distinguished. The joint was very painful, especially at night. 
The tongue was rather white with teeth-marks at the edge — the pulse 110, 
temperature at 4 p.m. 100.2°. He had a distaste for food, but was very 
thirsty ; the urine very acid, contained great abundance of lithates, but no 
albumen. I made out that the first affection, that of the right knee, had 



154 DISEASES OF THE JOINTS. 

come on after he had been standing in the river fishing without water- 
proofs. 

I ordered a leather double splint to be made — the knee being kept 
nearly straight, and an ointment consisting of three parts of the iodide of 
lead, five of the iodide of potass ointment, to be kept applied by means of 
strips of lint — prescribed the effervescent citrate of ammonia every four 
hours. To leave off sherry and beer, and to take instead 1J oz. of whiskey 
in the middle of the day and the same quantity at night — also ten grains 
of Dover's powder at bedtime. 

October 6th. — Very much better ; pain had very much decreased (partly 
attributable to the splint), and the swelling was less. The pulse had dimin- 
ished in frequency. Appetite returning ; temperature nearly normal. Less 
discharge of lithates in the urine. 

October 13th. — Still improving — to discontinue the ammonia and to 
take iodide of potash with bicarbonate and citrate of potash. 

December 5th. — The case went on uninterruptedly well. On November 
28th frictions were ordered and swinging the leg, with a two-pound weight 
attached, for ten minutes twice a day, and then to reapply the splint. At 
above date he returned to Ireland, promising to carry out all the ordinances, 
increasing week by week the passive movements, and after a time to use 
active motion, and to discard first the inner, then the outer case. In the 
spring of 1877 he returned, able to walk without a stick. The stiffness re- 
maining was shown by an inability to bend the knee to the full, or to kneel 
on it without getting rapidly fatigued ; and, what he more disliked, inabil- 
ity to quite straighten the joint. He was shown how to lie prone on a sofa, 
weight and swing the leg in the direction of extension, and he rapidjy got 
better, so that at the end of June he was able to go with his regiment, 
which was ordered to Malta. 

April, 1878. — Captain B. wrote that he had met with an accident in step- 
ping into a boat, and the knee had again swollen and become painful. He 
thought, too, that the climate did not suit him ; shortly after he obtained 
leave of absence. When I saw him in May, it was evident that the joint 
was not by any means in so bad a state as on the first consultation ; but he 
said that it had been much improved by the voyage and the reapplication 
of the leather splints. He was, however, very rheumatic, and a repetition, 
with slight variation, of the same means, was followed by rapid improve- 
ment, and in August he rejoined his regiment just then ordered to 
India. 

Case XXXIX. — Mr. G., aged thirty-nine, asked me to call on him — suf- 
fering from knee-joint disease, March 2, 1874. His business, connected 
with certain railway appliances, led him occasionally to ride on the engine. 
About a fortnight previously he had thus got wet through, and was too 
cold to feel his feet, so that he fell and strained the knee, apparently only 
slightly, nor did he feel more than slight stiffness till thirty-six hours 
before sending for me. Two nights previously he woke up suddenly with 
severe pain, which lasted the rest of the night. In the morning the pain de- 
creased, and during the day was so slight that he expected to get well rap- 
idly, but again in the night a more severe pain set in, and lasted until late 
in the morning. I saw him on the same afternoon, and found some py- 
rexia, temperature 101.3°, quick pulse, no appetite — urine loaded with 
lithates. Ordered a leather splint— blisters (merely rubefacient) above the 
joint. Two grains of blue pill and half a grain of colchicum night and 
morning for four days, afterward medicines to diminish acidity of, and lith- 
ates in the urine. He had been drinking sherry and champagne ; these 



SUBACUTE KHEUMATIC SYNOVITIS. 155 

■were stopped. Morphia was given at night ; the case proved rather obsti- 
nate, and he had to be kept in bed nearly six weeks— and then was allowed 
to lie on the sofa. Five grains of iodide of potass with three of carbonate 
of ammonia and fifteen minims of the tincture of acteea racemosa. Knee 
tightly strapped with the mercury and ammoniacum plaster. 

May 19th. — Knee very much better. Passive movement by swinging 
with weight attached. Friction rapidly diminished the size of the joint. 

June. — He could walk well, and went by my advice to Baden, where he 
quite recovered ; on his return later in the year no trace of the malady 
could be seen. 

Case XL. — Mr. G. L., aged twenty, struck his knee, when hunting, 
against a gate that swung back upon him, in March, 1879. The weather 
was cold and rainy, he was wet, and had some distance to ride home. The 
knee was very painful and somewhat swelled ; he kept wet rags upon it, 
and in a day or two it was much better, but he still for a fortnight had 
difficulty in walking ; sometimes at night he was awoke by pain, and had 
to rub the knee, and alter its position. These troubles, however, seemed to 
get fetter, until in June, when he, in playing lawn-tennis, sustained some 
slight strain, which obliged him to stop, and gave considerable pain. Three 
days afterward he sent for me, June 16, 1879 : I found the joint swollen, 
rather hard and resilient, not containing any excess of fluid, rather of a 
square shape. The urine contained a considerable deposit of lithates, va- 
ried occasionally by lithic acid red sand. He was in the habit of taking 
wine rather freely at dinner, and also usually a rather large glass of sherry 
— sometimes two — in the afternoon. His tongue was clammy, rather white, 
and indented at the edges by the teeth. I kept him in bed, and had a splint 
moulded to the knee. Ordered a rather smart purge, effervescent ammonia 
and entire abstention from wine, permitting, however, a little whiskey and 
water ; the pain was very considerable, and he had to take one-half grain 
of morphia every night. In eight days I allowed him to lie on the sofa, 
and shortly after to drive out while the splint remained on and the knee 
was tightly strapped. As soon as he got out and to his clubs he began, in 
spite of my direction, to take sherry again, the urine again contained lith- 
ates, and the knee began to be painful, especially at night, waking him two 
or three times, and then "keeping him some time from sleep. After a short 
sermon on his folly I ordered him the Woodhall Spa water, six ounces of 
whiskey in three doses during the day, oleate of mercury 5 per cent., to be 
rubbed in night and morning. 

August 15th. — Very much better, sent him to Kreuznach. When he 
returned to England in the beginning of October his knee was nearly well, 
but he has been obliged to see me on several different occasions. The joint 
eould not be quite as much bent as the other, and a very slight enlarge- 
ment remained. His troubles were occasional returns of pain, more espe- 
cially at night ; these are always, if not directly, traceable to some error of, 
diet — at least are always combined with lithates in the urine. He hunts 
and shoots without annoyance. 

Case XLI. — Gr. D., aged thirty-five, foreman of builders' carpenters, 
rather addicted to drink, but short of absolute intemperance, came under 
my care in Charing Cross Hospital, June 6, 1875, with a considerable swell- 
ing of the knee. The joint contained some excess of fluid, but was rather 
hard and resihent, square in form. He had got wet through several times, 
but had no remembrance of an injury. He thought the disease began about 
eighteen months previously, when he had to lay up for about ten days, and 
then got to work again, although with some considerable pain and dim- 



156 DISEASES OP THE JOINTS. 

culty. The present attack began seventeen days previously ; he had kept 
quiet at home for a fortnight before presenting himself. 

A large-sized aspirator needle was passed into the joint, and three ounces 
one drachm of a slightly opalescent fluid withdrawn, which on standing, de- 
posited abundance of cells. The emptied membrane, when moved by the 
palms over the bones, crepitated, and a number of little bodies, from the 
size of a mustard-seed to that of a dried pea, could be felt. The limb was 
put on a Maclntyre splint, iodide of potass three parts and the blue oint- 
ment one part were kept applied, and firm pressure by bandage employed. 

June 14th. —The knee had not filled again, crepitation of synovial mem- 
brane less evident, strong strapping-plaster applied. 

July 2d. — On removing the strapping, I found the joint sufficiently well 
to permit the man getting up, a leather splint being moulded on the out- 
side. 

July 20th. — Discharged at his own request, could walk with a stick, or- 
dered to procure an elastic web-bandage and to use rather strong pressure 
over the joint. The little bodies could not be felt, but a slight silken crepi- 
tus, when he bent and straightened the joint, was evident. , 

Case XTJT. — Jane S., aged forty-nine, was admitted intp Charing Cross 
Hospital under the care of Mr. Hancock, May 7, 1867. The woman had 
suffered for twelve years from disease of the left knee. She had had acute 
rheumatism in 1854, and though she appeared well she always had some 
pain and trouble in that knee. Since then the joint had occasionally been 
very painful and swollen, and had got better alternately, but in the last 
eighteen months has been nearly always bad, incapacitating her from any 
employment. 

The joint was generally rather hard, somewhat square in shape ; the 
tibia movable in many abnormal directions. As the knee was plainly dis- 
organized, and the patient's health much affected, Mr. Hancock amputated' 
in the lower third of the thigh on May 25th. 

Examination. — The synovial membrane was greatly thickened by tough 
fibre-tissue ; its inner surface was rugous as though in folds ; it was un- 
even rather than rough. The latter ligaments were buried in this tissue, 
and in great part changed into a like material. The cartilages were very 
peculiar — in some spots very thin and of a light brown hue, in others ab- 
sent, not by ulceration, since the surface-level was in such places unaltered 
(ossification of cartilage). In one spot on the inner condyle was a depressed 
part, about the size of a sixpence, in which the cancellar bone-structure 
could be seen. Lying in the cavity of the joint was a piece of cartilage 
with the remains of the articular lamella still attached, which precisely fitted 
this hole, which was surrounded by an almost complete ring of ossified car- 
tilage. At the back of the condyles portions of the cartilage were fibrilla- 
ted. On the tibia only a few parts were covered by thinned cartilage ; in 
other parts it was fibrUlated or had disappeared. 



CHAPTEK VH. 

ON SOME OTHER FORMS OF SYNOVITIS. 

The strumous and rheumatic diatheses are those which chiefly produce 
or maintain a chronic inflammation of the synovial membrane ; but there 
are besides two other conditions having the same effects : these are Syphi- 
lis and Gout. 

Syphilitic synovitis, although rare, is sufficiently common to deserve 
some notice. The malady appears in two manners, the one, combined with 
an acute outbreak of syphilitic intoxication — pyrexia, throat ulceration, and 
shin eruption — is poly-articular and usually evanescent. At present I am 
in doubt whether the joint-affection is a direct sequela of the syphilitic 
poison, or one of the absorption diseases analogous to those which occur in 
the course of measles and other exanthemata. The other form, essentially 
chronic, is mon-articular, the symptoms of which lead me to believe that 
the inflammation always spreads from the periosteum. In some cases I have 
seen, nodes on the shin were present at the time, giving severe nightly 
pain ; in others, these pains were subsiding ; in one a suppurating node 
close to the joint had been incised. 

Syphilitic eruptions are often present at the very time when the chronic 
joint-attack commences, and by proper inquiry a specific history can gener- 
ally be made out. I am not aware of any case in which this disease has 
occurred previous to other constitutional effects of the lues. 

The disease is confined to the middle period of life ; its usual history is 
this : The patient having been subject to the usual secondary and tertiary 
symptoms of syphilis, labors during some days or weeks, previous to any 
complaint having been made of joint disease, from nightly pains of the 
bones, probably also from swellings along the course of the shins, with whose 
aspect and history every surgeon is but too well acquainted ; then at some 
period a joint becomes painful, and swells. At first the tumefaction of the 
part is -slight, and is not so much due to effusion of fluid into the cavity, as 
to an exudation into the peri-articular tissues : this is evidenced by the want 
of fluctuation and the softness of the parts beneath the skin ; they do not 
pit, but they have a tendency to do so ; very slight pressure with the fin- 
ger whitens the part. Soon after the commencement of the disease, an aug- 
mented secretion of fluid into the synovial sac takes place ; increased heat 
is perceptible, and occasionally the skin has a pink flush. During these 
manifestations of syphilis there is commonly a nightly pyrexia of 100° or 
101°. The pain is, at the early stage, very severe, particularly while the 
patient is in bed, and at the first commencement of the disease ; when in- 
creased secretion into the cavity has taken place the pain very much sub- 



A less usual form of malady arises with one of those acute outbreaks 
of secondary or tertiary disease, that occasionally occurs in constitutions 
considerably impaired. The usual symptoms are these — a somewhat vio- 



158 DISEASES OP THE JOINTS. 

lent skin eruption, probably lepra, psoriasis or rupia and ulcerated 
throat, are accompanied by severe though somewhat vague and wandering 
imins in the bones, the back of the neck and jaws — the suboccipital and 
other lymphatic glands swell, the pyrexia is well marked even in the day, 
the nightly rise is considerable. A few such cases suffer from joint dis- 
ease, which is multiple and pretty severe ; but even without treatment is 
usually transient, and with proper medication disappears very rapidly. 

There is great difficulty in concluding or in proving that any one iso- 
lated case of such disease is a true syphilitic manifestation, especially as 
upon sufficiently persistent inquiry some admission of exposure to cold 
can from most persons be elicited, and, as we frequently find, combined 
with the other troubles irritation of the Schneiderian, laryngeal, and pharyn- 
geal mucous membranes which may arise from catarrh, syphilis, iodism, or 
even mercurialism. Still, although in some instances the joint-affection 
may be absorptive or slight rheumatism concurring with a certain cachexy ; 
yet I think sufficient evidence exists to show that there is a poly-articular 
subacute syphilitic synovitis unconnected with bone or periosteal disease. 

The course of these two forms of the malady is different, the former is 
often a somewhat obstinate, but not a severe disease ; it has a tendency to 
recur, when the next efflorescence of the poison takes place, and it leaves 
the joint very susceptible to cold. The latter is as I have said a subacute, 
generally a transient affection. I have never seen either of them lead 
to ulceration of cartilages or permanent injury to the joint. The knee 
and ankle are most prone to these attacks, but the elbow stands not far 
behind. 

Some difference in managing these two forms of disease must be ob- 
served. The treatment of the former may follow the usual lines of anti- 
syphilitic practice. Mercury in small doses, and* of all preparations the 
perchloride or the iodide is the best, as less injurious to the constitution 
and more antagonistic to the disease than any other ; while if nodes with 
tender periosteum be present iodide of potass will have its well-known in- 
fluence. In one case rapid amelioration resulted by a compress covered 
with mercurial ointment bandaged on the limb, while iodine was given by 
the mouth. 

The latter form of the malady is always in my experience combined 
with considerable debility, with a state of system in which either mercury 
or iodine is apt to prove injurious, until by some other means the hectic- 
like pyrexia has been overcome. Either quinine or iron, if they can be 
borne, or indeed a combination of both, may often be given at once ; or, if 
such remedies are not as yet suitable, vegetable bitters with or without 
acids, and the extract of cinchona, may be used. If the nightly pyrexia be 
very considerable, 102° to 103°, the effervescent citrate of ammonia will 
probably prove ihe most fitting remedy. After this phase has passed a 
combination of mercury with quinine or with iron (Formulae IX., X, XI.), 
either in liquid or in pill, will probably be desirable. 

The local treatment is first of all rest, with a fitting splint to secure im- 
mobility of the joint, and superficial counter-irritation by means of iodine, 
or of flying blisters, only kept on long enough to produce considerable red- 
ness of the surface without vesication ; the redness may afterward be 
kept up by the tincture of iodine. It would seem, from the fact of pain 
being most severe when the patient gets warm in bed, that cold would be 
a soothing application ; this, however, is far from the fact ; heat, by means 
of hot salt or hot-water bags, although producing pain for the first few 
minutes, procures a more rapid relief than cold. Mercury in the form of 



ON SOME OTHER FORMS OF SYNOVITIS. 159 

oleate may be employed with great advantage, especially in cases of 
debility, when we would wish to avoid other modes of administration. 

Gout is a disease produced by the presence in the blood of uric or 
lithic acid ; the local manifestation is caused by the deposit of this mate- 
rial, in combination with soda, in the various tissues of the joints, produ- 
cing a very painful articular inflammation. Eheumatism is also marked by 
superabundance of lithates as evidenced by the urine, but no lithic salt is 
in rheumatism deposited in the joints ; therefore, though both gout and 
. rheumatism have the presence of lithates in common their pathological 
and clinical conditions are different. It hardly comes within the scope of 
this work to describe fully either the symptoms, the treatment or indeed 
the general pathology of this disease ; but a few remarks upon the mode 
in which the local action is produced appear desirable. 

The attacks of gout, like those of rheumatism, come on at irregular in- 
tervals, although the poisonous matter accumulates regularly, pari passu, 
in the blood. It seems that the uric acid* may go on accumulating to a 
certain point without producing any painful symptoms, and that then a 
severe attack will come on, with or without some accidental exciting cause. 
Each of these attacks is attended with a more or less rapid and plentiful 
deposit of lithate of soda into the soft textures of the joints ; generally at 
first of the small joints, as of the toes or fingers ; but sometimes of a' large 
joint, as the knee, the largest in the body, will be the only one affected. 

In the acute attacks of the disease, a quantity of the salt is partly dis- 
solved, partly suspended in the synovial secretion, giving it a milky or 
rather a chalk-and-watery appearance ; and when the fingers are moistened 
with this fluid, and it is rubbed between them, it imparts a gritty sensa- 
tion — at the same time a larger quantity of fluid than the norm is secreted ; 
during these attacks, and also during a more chronic and persistent suffer- 
ing, the urate of soda is deposited in the cartilages, the peri-articular tis- 
sues, ligaments, and even in the bones. The deposition takes place in the 
form of a chalk-white, gritty powder, in which, under the microscope, aci- 
cular crystals are found to be abundant. At first the salt is suspended in 
the exudation fluid, but soon the mere liquid is absorbed, and the concre- 
tion is left dry and pulverulent among the fibres of the part. Owing to 
the opacity thus produced, there is considerable difficulty in seeing the his- 
tological position in which the salt is stored ; but from many investiga- 
tions which I have made, it seems to me that the atoms group themselves 
round the cells of the various structures. 

The cartilages are sometimes found covered on the surface with the 
lithate ; this happens during the most acute phase of -the disease, while 
the joint secretion is rendered milky ; the salt then slowly deposits itself 
on all surrounding parts. Frequently are to be seen little white spots in 
the substance of the cartilage, and if sections be made through these with 
a sharp knife, they will be found broader and larger in the depths, than on 
the surface of the structure. The opacity in these places is so great, that 
it is impossible to procure sections thin enough to be transparent ; but by 
teasing out portions very minutely with needles, it may be seen that the 
lithate occupies chiefly the hyaline structure close to the edge or wall of 
the corpuscles, while the cells themselves remain free up to a certain point. 
At some period, however, the cell-walls become invaded, the cells them- 
selves atrophied, when ulceration of the cartilage commences. 

In the peri-articular tissues and ligaments, the same mode of deposi- 
tion is followed ; the cells remain ^themselves free from the salt for some 



160 DISEASES OP THE JOINTS. 

time after the fibrous intercellular structure has been invaded. This can 
only be seen by careful and minute division with needles. In a case that 
was very far advanced, I found the whole internal lateral ligament of the 
knee converted into a cyst, which contained a hard almost dry lump of 
lithate of soda, about as large as the last joint of the thumb. 

The bones, on account of their solidity and the compactness of then* 
elements, receive this deposit much more slowly than the softer tissues. 
In them also it* occupies a position round the bone-cells, filling up the 
intervals between the canaliculi." 

The histological sequence of this deposit carries out entirely the pathol- 
ogy of other joint inflammations, as laid down in this treatise. But it should 
be remembered that lithic acid is in gouty persons deposited in other parts 
as well as in the joints. The helix of the ears is a very favorite place for 
little cuticular concreta, which show white through the epidermis ; these 
spots are usually about the size of a mustard-seed, but sometimes consid- 
erably larger ; another place in which small deposits are found is the sub- 
conjunctival space of the lower •eyelid. Eveiy white spot in these localities 
is not urate of soda ; sebaceous concretions, or even, as Dr. Garrodo bserves, 
cholesterine and epidermic scales, accumulating in spots about the eyelids 
and face, have much the same external look as the gouty salt. A needle 
puncture and a microscope will always decide in cases of doubt the nature 
of the deposit. 

These concreta, whether in the joints or elsewhere, are deposited from 
the blood, which, as the above author has shown, is in gout invariably rich 
in uric acid, and this richness depends on failure of the kidneys to excrete 
that compound in sufficient quantity. It must not be overlooked that some 
gouty persons suffer habitually from slight albuminuria, others only during 
the paroxysm. I believe it was the late Dr. Todd who first pointed out the 
gouty kiclney as he termed it, viz., a contracted granular organ with a few 
white lines of uric acid among the tubuli, and more sparse deposit in mi- 
nute nodules in the cortical substance. The contracted or atrophied state « 
of the kidney depends rather on diminution of the cortical, the essentially 
secreting portion, than on decrease of the medullary parts. 

There is, I have glanced at the fact more than once, a remarkable affinity 
or correlation between lead -poisoning and gout ; that is, persons whose 
systems, by accident or avocation, have absorbed lead, are extremely prone 
to be attacked by certain forms of gout, and persons who have undoubted 
attacks of gout, or even such as are of gouty descent and habit, are on very 
slight contact with that metal extremely liable to suffer from lead-intoxica- 
tion. Of this I shall give an instance (Case XLTV. ). 

Symptoms. — The changes in. the joints above described may be brought 
about by a number of acute attacks, succeeding each other with consider- 
able rapidity and regularity, the intervals being in some cases quite free, 
in others simply periods of less suffering, or they may result from a con- 
tinuous chronic gouty condition, with perhaps some occasional exacerbations 
that may be rather violent or but slight exaggerations of the usual state. 

Acute gout at first attacks the smaller articulations, and has a special 
predilection for the first metatarso-phalangeal joint. The first few attacks 
usually come on when the patient is feeling quite, perhaps particularly welL 
After a time the paroxysms are preceded by considerable irritability, often 

1 In one or two post-mortem examinations of gouty subjects, certain joints have 
b=en found anchylosed; this condition I believe to be not a direct sequela of gout, but 
the result of synovitis, which gout may in the first instance have produced. 



ON SOME OTHER FORMS OE SYNOVITIS. 161 

by a sharpness of temper, which apprises the man's wife and children, even 
though he himself may not know it, that a " fit of the gout " is coming. 
One night (the attacks rarely begin in the day) the patient wakes with a 
sharp stab of pain in the toe, which leaves behind it a throbbing burning 
heat, with aching fulness and sense of bursting, increasingly severe until 
it seems unbearable. The skin becomes red, tight, and shining, veins are 
clearly marked and raised above the surface, the whole neighborhood is 
swollen ; the patient protests against the very tender part being touched ; 
but when this is done some slight pitting occurs. In the morning the pain 
generally abates, the patient gets a little sleep, and during the day, as a, 
rule, he is so far easier, that he (unless well acquainted with his foe) may 
hope for a placid night. But hardly does he get to bed than some throb- 
bing warns him ; perhaps he just gets to sleep when a fresh dart of pain 
rouses him to another night of what becomes little short of torture ; and 
so on through a weary succession of nights, perhaps as many as ten or 
fourteen,' the unfortunate victim suffers. When several such attacks have^ 
occurred, tophaceous deposits may be seen in the skin as little white round 
patches, usually raised from the surface. The foot is constantly tender, 
ordinary shoes cannot be worn, and more or less lameness results. . Dur- 
ing this time a certain pyrexia, more especially in that form called sthenic 
or rich gout, is present, and indeed I have observed that on each nightly 
attack a rise in the thermometer precedes the pain ; the skin is hot and 
dry, the urine high colored and scanty — often extremely scanty. The con- 
dition of tongue, appetite, and bowels varies greatly. The attacks of poor 
gout, that which affects more feeble persons, especially those who are 
poisoned with lead, are mere exacerbations of the chronic gout. The 
affected part is but slightly more painful than usual, redness is not well 
marked, nor is venous engorgement ; on the other hand more oedema is 
usually present. After either form of attack desquamation ensues, and 
this may decide upon the reality of an asthenic "fit," which might other- 
wise be doubtful. 

Chronic gout, although any one moment of the disease may be less pain- 
ful than an acute sthenic attack, is a distressing and destructive malady, 
because the patient is rarely quite free ; the fits, though less violent, are 
more frequent — sometimes almost continuous. The joints, first and chiefly 
attacked, undergo more destructive alterations, and fresh parts are con- 
stantly being invaded. If we can insure that the disease will remain in the 
joints, the patient may consider himself fortunate ; this is not by any means 
always the case, as the heart, stomach, brain, or other vital organs, may be 
attacked (irregular or misplaced gout). 

The singular distortions and alterations of form, which are sometimes 
produced by this malady, would be incredible, if presented to us for the 
first time. I have now a gentleman under my care whose right hand pos- 
sesses no joint, in normal posture or shape ; the extremity looks rather 
like a clump of horseradish root than part of a human limb ; every promi- 
nence, and they are innumerable, is crowned by a white spot of chalk-stone ; 
and almost every depression is red and dusky from hypersemia and venous 
enlargement. 

The diagnosis of this malady, when the fit is in full bloom, is unmis- 
takable ; to distinguish more chronic and milder forms is less easy. Fam- 
ily history may greatly help (atavism is the not invariable rule of descent), 

1 Cases have in former times lasted several weekR. I do not think that with our 
improved knowledge and therapeutics they should do so now. 



162 DISEASES OF THE JOINTS. 

and examination of the ears and eyelids should never be neglected ; a]t the 
same time it must be remembered that a gouty person may have non-gouty 
maladies, yet will hardly suffer inflammations that do not partake of the 
gouty nature, even though traumatic. Anomalous vague distressing symp- 
toms, for which no reason can be found, as sleeplessness, bad dreams, pe- 
culiar palpitations, and flushing heats, certain forms of indigestion with 
distention, in old men obstinate matutinal erections, should lead us to ex- 
amine for gouty deposits on the skin, but especially to search in the urine 
for lithic acid, which, unlike that fluid before an acute attack, will often be 
found loaded with the salt. 

Treatment. — As gout has many phases, so must the treatment be differ- 
ently directed. In an early acute attack of the sthenic variety, the first 
object must be to check the pain, and this, if possible, without the use of 
opium, which diminishes the action of the kidneys. Now, of all swift means 
of effecting this object, colchicum is the most certain, but it is a remedy 
which requires some caution, since, in spite of the dictum of a great author- 
ity on gout, it appears certain that, unless carefully administered, it may be 
followed by one of two evil consequences : early repetition of the attack, a 
reliquum of chronic, perhaps of atonic gout. The less robust the patient, 
the more caution must be employed ; it is a depressant of the heart's action. 
If, however, we know that we are making use of a tool which cuts both 
ways, we may judiciously deal with an early attack in a robust person, by 
giving at once twenty or thirty minims of the wine of colchicum combined 
with a diuretic, as the bicarbonate, acetate of potash or both with some 
bromide of potassium, which I have often found of great advantage. But 
if the pulse be low,' under seventy beats per minute, a little carbonate of 
ammonia may be judiciously added. 1 If the pain be very severe, the col- 
chicum dose may be even larger. Afterward, ten or fifteen minims, with 
the same quantity of salines, may be given three times in the course of the 
day ; but cautiously enough to keep in reserve room for the administration 
of another large dose, if at night a recurrence supervene. 

In the meantime we must strictly enforce a non-nitrogenous and non- 
stimulating diet. All beer and wine must be forbidden, and all meat ; the 
ideal regimen is simply the bread-stuffs, arrowroot, tapioca, etc., with 
plenty of diluents. But some patients will not or cannot bear this feeding, 
and the digestion of certain persons is uneasy without some slight stimu- 
lant ; in such cases a little light white-fish, and a small quantity of sound 
old whiskey, may form the compromise between what is best and what is 
feasible. If the pain, in spite of colchicum, be severe, the best form of 
sedative is the salicylate of atropia, the mode of whose preparation will be 
found among the formulae (Formula XVI.) ; if this be inadmissible a small 
subcutaneous injection of morphia may be necessary. 

Under such treatment, varied according to circumstances, an attack of 
acute sthenic gout ought to pass away rapidly. 

But much can in the intervals be done to keep such attacks at a dis- 
tance. Even when, as with many patients, warnings appear, such as unu- 
sual irritability of temper, peculiar itchings and heat of skin, certain 
shooting neuralgia-like pains, etc., the hot-air bath is often efficacious, 

1 Purging is only desirable if there be either constipation or what is less usual teas- 
ing, insufficient alvine discharges ; or again, if the hue of the skin and conjunctiva 
be decidedly icteroid, podophyllin, leptandrin or blue pill, the two former in prefer- 
ence, may under either event be combined with other purgatives, to which from a half 
to one grain of the extract of colchicum may be added. 



ON SOME OTHER FORMS OF SYNOVITIS. 1(33 

especially if plenty of water be drunk daring perspiration, and afterward 
saline diuretics and the carbonates — lithia perhaps, though I have failed to 
find in it any peculiar efficacy. At night, a purge containing either the ex- 
tract or the wine of colchicum may be administered. 

During the period of complete freedom, the same salines may be rather 
more sparingly used, and combined with them the iodide of potash, or 
unless some state of heart forbid, small doses of digitalis ; this drug is not 
mentioned in therapeutic books, or elsewhere as a remedy for gout, but I 
have used it too often, and with too good effect, to doubt its value. I have 
never employed it during an acute attack. 

Chronic atonic gout is to be managed after a rather different system ; 
the possibility of lead-poisoning at some time, even if not present at the 
moment, must not be overlooked, and the presence or absence of albumen 
must be verified. While in the latter case diuretics and iodine may be 
employed, their use must be omitted or carefully watched in the former. 
The bitter tonics, such as gentian, calumba, chiretta, are generally better 
digested if some stomachic be added — even bark, either as quinine or the 
extract, may be employed ; infusion of ash leaves (bitter diuretic), greatly 
extolled, is of somewhat problematical value. The lighter preparations of 
iron may be cautiously used. If any appearance of lead-intoxication be 
traceable, iodide of potass, at first in very moderate then in larger doses, 
combined with diuretics, is the best and most essential remedy. 

Frequently one of the alkaline and chalybeate springs will answer bet- 
ter and more decisively than all medicine — Harrogate, Buxton, or Bath, 
Schwalbach, Vichy, Aix, and a host of others, stand open to the choice of 
surgeon and patient. 

The local treatment of gouty limbs has not, I think, been sufficiently 
considered, probably because as the materies morbi is certainly in the blood, 
it has been supposed that applications to the inflamed part could do no 
good. Thus, with the exception of wrapping the inflamed limb in cotton- 
wool or bathing it in lukewarm water no mode of treatment has been as 
yet devised. During the acute fit, however, the pain may be relieved, gen- 
eral treatment being of course also employed, by soaking cotton-wool in 
chloroform, protecting it by another layer, and covering the whole with 
thin mackintosh. Or equal parts of chloral and camphor, rubbed together 
into an unctuous semifluid, may be applied on lint, and similarly covered. 
Aconite as a local remedy sometimes succeeds. More certain than any of 
these is morphia or atropia, dissolved in oleic acid. 

During the remissions much may be done to prevent the crippling and 
distortion which goes on even without pain as a result of depositions, which 
took place during the fit. Passive movement and rubbing carefully em- 
ployed so as not to bring on inflammation, especially upward rubbing with 
glycerine or thirty drops of oleic acid slightly smeared on with the finger- 
tip ; a solution of bicarbonate of potash, sometimes combined with a little 
of the iodide, applied on lint and guarded with oil silk, are all valuable 
remedies, if carefully and persistently employed. Their use may often 
make all the difference between slow distortion and gradual recovery of the 
limb. 

Case yTJTT. — Mr. J. P., aged sixty-five, sent for me April 3, 1864. He 
had been suffering from an attack of gout, which had kept him in bed 
twenty-five days. He had been subject to such attacks for the last fifteen 
or twenty years ; they had recurred since four years ago much more fre- 
quently. T fon pd thai, in thp. r ir ° or> + in^oaa he had been treated by purga- 



104 DISEASES OF THE JOINTS. 

tives and colchicum — the latter injudiciously used, inasmuch as, the disease 
not yielding, more and more had been given, and at the time of my first 
■visit he was taking six drachms of wine of colchicum a day, and at the same 
time sherry, since he had become weak, was ordered. Both toes, both 
ankles and knees, the right wrist and left shoulder, were all affected, pain- 
ful, thickened, and very tender. 

The colchicum and the sherry were at once stopped, bicarbonate of 
potash and carbonate of ammonia ordered, and whiskey instead of sherry. 
After a few days manifest improvement commenced. One grain of quinine 
in pill twice a day. After five weeks he was able to go downstairs, and in 
four months he could attend to his business in the city, walking with two 
sticks. During the first year he took 10 grains of bicarbonate of potash 
and 3 of the iodide, with 8 minims of tincture of digitalis thrice a day, 
then the doses were rather diminished. In the second and third year I 
sent him to Harrogate for sis weeks each time. But he managed himself 
with these medicines, and by means of passive movements and rubbing, the 
joints were greatly restored. The only gouty manifestation since 1866 was 
herpes and itching ; but I saw him occasionally for some other troubles. 
Later, certain circumstances caused him greatly to regret complete impo- 
tence (want of erectile power), which he attributed entirely to the alkalies 
and digitalis ; but as he was at that time seventy-seven, it is possible that 
a cause other than medicinal was to blame. 

Case XLTV. — Mr. C, aged thirty-one, a robust man, had, eight months 
previously, his first attack of gout ; had threatenings two days ago, which 
being worse this day, March 25, 1871, he sent for me. I treated him with 
slight purge and 20 minims of colchicum wine. Farinaceous diet, rest in 
bed, 10 minims of colchicum and alkalies and diuretics thrice a day ; he 
was getting better, and I hoped the symptoms would pass. But on the 
morning of the 2d, being begged urgently to call, I found him very ill, 
with low, weak pulse, abdominal pains, and the foot inflamed, pitting, and 
of a venous color ; he had, too, a very peculiar dusky hue, which even per- 
vaded the conjunctivae. I examined the mucous membrane of the mouth, 
and found the lead hue on the gums. On inquiry it appeared that on the 
night of the 31st, feeling the foot better, he hoped to expedite matters by 
the use of a cold lotion, and applied, what happened to be in the house, 
some diluted liquor plumbi, and kept it on till he was awoke with pain at 
4 a.m. of the 2d, nearly thirty-two hours. This changed the character of 
his attack to atonic gout. He was treated with iodide of potass and tonics, 
with an occasional small dose of colchicum — but was very ill for some days, 
and the malady proved very obstinate. 



CHAPTER Yin. 

HYDARTHROSIS OR HYDROPS ARTICULI. 

These terms denote simply that the affected joint contains an abnormal 
amount of watery, i.e., non-puriform fluid ; but when a condition derives 
its name from one markedly prominent symptom, it always happens that 
different forms of disease become confounded under one term. Thus a 
chronic accumulation of sero-synovial fluid, within an articular cavity, may 
be either a mere slow hypersecretion, or the relic of an acute serosynovitis 
— it may be an accompaniment, a sequela of a false cartilage — a conse- 
quence of the development of synovial fringes, with innumerable smaller 
or larger movable bodies (see Chapter IX.) ; or lastly, the commencement 
and early symptom of chronic rheumatic arthritis. These maladies all dif- 
fer in many particulars, but one must not lose sight of the fact, that a 
simple hydrops, with no other change of the synovial membrane than hy- 
peremia, will, in the great majority of uncured cases, lead to hypertrophy 
of fringes — this to development of small mures articuli — and in many cases 
to arthritis deformans. Yet a simple hydrops leading to these results is 
very different to maladies commencing at once in the above organic changes, 
hypersecretion being a mere symptom. False bodies and arthritis defor- 
mans belong to other chapters of this work, but while now engaged in 
considering hydarthrosis as a primary malady or secondary to acute dis- 
ease, we shall never be entirely able to lose sight of its correlations with 
the other two conditions, nor must we ignore the proneness of either forms 
of joint-dropsy to induce, or at least to be followed by considerable change 
of structures. 

Case XLV. — Benjamin , aged seventeen, weak, emaciated, was 

brought to me by his mother, July 15, 1857, for a burn he had received by 
falhng in a fit upon the fire. The boy's fits had got worse of late ; he was 
of weak intellect, and getting still more so ; he was also growing thinner, 
although his appetite was voracious ; he had a very bad cough, and expec- 
torated a great deal. 

His mother showed me his right knee, which was much swollen. It 
appeared that two years before he had an accident to the knee, causing 
great pain and swelling, and he was taken to the Middlesex Hospital : the 
joint was well when he came out ; but for the last fifteen months it had 
been enlarging ; it did not appear to produce pain, but only caused him to 
walk with the knee a little more straight than the other. The burn was 
treated and the knee strapped ; I was desirous, after a time, of injecting the 
joint, but the mother was not inclined to let him undergo any treatment. 
The boy constantly getting weaker, expectorated more, and had longer fits ; 
and on the 5th or 6th of October, 1859, he died. 

October 7, 1859. — I obtained permission to make a post-mortem exami- 
nation, simply for the sake of seeing the state of the articulation. 



166 DISEASES OE THE JOINTS. 

During life the condition of that joint had been as follows : It was very- 
much increased in size, simply by the presence of fluid in the cavity ; the 
peri-articular tissues were not at all swollen ; the fluid felt very near the 
finger ; the chief tumefaction was at the front of the. thigh, considerably 
above the point to which the synovial membrane ordinarily extends ; the 
patella was pushed rather forward, away from the condyles of the femur, 
but not so much so as is the case in acute synovitis, with infinitely less ac- 
cumulation of fluid ; there was a little bulging of the joint on each side the 
ligamenlum patellae ; there had been no pain, unless he attempted to flex 
the leg considerably, but the joint was rather stiff. 

The skin was reflected carefully back from the front and sides of the 
lower part of the thigh : the muscles, namely, rectus and vasti, were seen 
pale and thin, particularly the two last ; they seemed spread out, and their 
fibres separated ; when the rectus was turned back the same was found to 
be the case with the crureus : these muscles were dissected as low as could 
be managed from the white glistening outer walls of the pouch that ex- 
tended high up beneath them, and this was punctured in such manner as 
to prevent, as much as possible, any loss of the fluid ; the sac was then 
opened up by turning back the patella ; there was extreme redness and 
vascularity of the inner surface of the synovial membrane ; this was most 
marked in the folds between the femur and the inter-articular cartilages, 
also at the sides of the patella, but there was one part in the subcrureal sac 
which was intensely congested : the folds first mentioned were very velvety 
in texture, owing to turgescence in the vessels, but the substance of the 
villi themselves did not seem much increased ; the cartilages had lost .their 
opal bluish sheen ; had become dull, milky, and soft, so as to take the im- 
press of the nail : upon the anterior crucial ligament was a little cyst con- 
taining serum, the size of a pea, very like a blister ; there was no shred of 
false membrane upon the surfaces of the joint, or floating in the liquor. 
The fluid was eleven ounces in quantity, straw-colored, with some round 
spots like oil on the surface ; it had lost all thready quality, but had still a 
lubricating feel ; it was very like the fluid of hydrocele, and contained a 
good deal of albumen ; under the microscope the bottom of some, left 
standing in a conical glass, showed a few round cells. 

The textures around the joint were next examined ; they were found 
thickened, white, and glistening ; the increase was not by addition of crude 
unformed textures, but apparently by simply greater nutrition of the nor- 
mal parts, that is to say, the growth was uniform : there was no distinction 
of old normal and new abnormal textures. 

Case XL VI. — Benjamin W., aged forty, admitted under my care into 
Robertson Ward, April 12, 1878, with diseased knee-joint. The man had been 
treated in several Provincial and London hospitals with temporary benefit ; 
but the knee was becoming more and more useless. The disease began 
in an almost painless general swelling, more than seven years ago. At the 
time of admission the joint was greatly swollen ; fluctuating like a thick 
fluid ; painful, with a continuous dull, heavy ache and sense of distention ; 
starting-pains occasionally ; the tibia could be moved on the femur in al- 
most every abnormal direction. The knee measured 19£ inches against 14 
on the sound side ; the limb both above and below greatly emaciated 

April 25th. — At the man's very urgent petition, I amputated the limb at 
the lower third of the thigh. The man made a rapid recovery. The cavity of 
the joint contained only 3£ ounces of fluid. On turning up the patella and 
synovial membrane a peculiar change and increase in the tissue was found 
Its section exhibited the yellow edge of a soft, pulpy mass, not unlike the 



HYDAKTHROSIS OK HYDROPS ARTICULI. 



167 



flesh of an over-ripe or boiled orange, saturated in the same fluid as that 
contained in the joint, and on which its color appeared chiefly to depend. 
In the substance of this hypertrophic tissue was found a number of minute 

. loculi or spaces communicating more or less freely with one another, and 
containing the same fluid. The thickness of the tissue varied in different 
parts ; in the subcrureal portion it was about 1^ inch thick, and nearly ob- 
literated the cavity.' Its internal surface was warty, or might, in other 
words, be described as composed of a number of rounded irregular emi- 
nences or cones with their apices to the lumen, their bases to the periphery 
of the joint. This whole mass was surrounded by a white, dense, tendon- 
like capsule, thicker in certain parts than others ; there were no external 
ligaments save this thickened tissue. The crucial 
ligaments were sodden, softened, and much length- 
ened or loose. The fibro-cartilages remained, but 
they also were sodden, yellow, full of loculi, and in 
parts merged into the general hypertrophied mass. 
The cartilages were entire, but had beccrtne visibly 
fibrous over a great portion of the surface. Micro- 
scopic examinations were made in various ways of 
the hypertrophied mass. It consisted chiefly of an 
areolar tissue, composed almost entirely of yellow 
elements, wide-meshed, and scattered with cells and 
connective-tissue corpuscles distributed freely among 
them. White elements were rare, especially in the 
layers next the cavity, while in tracing the tissue out- 
ward the wavy fibres became more abundant. Yet 
there was no gradual transition from the tissue con- 
sisting merely of yellow and that of the capsule formed 
entirely by white elements. The loculi seemed 
simply enlarged tissue-spaces ; they were lined ir- 
regularly and patchwise by endothelium, and were of every variety of size, 
from that of a slightly exaggerated connective-tissue interspace to that 
which would hold a No. 4 shot. There were but two bodies, which might 
be regarded as hypertrophied fringes — these were one the size of a horse- 
bean, the other rather larger, each attached by a thin pedicle to an apex of 

' one of the conical projections above mentioned. They consisted of a more 
scattered and loose areolar tissue than the rest of the hypertrophied syno- 
vial membrane, and were soaked in the same yellow fluid. 

Case XLVII. — George M., aged thirty-two, died in Charing Cross Hos- 
pital, March 18, 1873, of cancer of the pylorus. During his lifetime I had 
been asked by my late colleague, Dr. Headland, to examine his left knee. 
I found the joint greatly enlarged ; the patella pushed forward ; the skin 
rather tense ; fluctuation was very distinct, almost as marked as in ascites. 
The subcrureal sac was more especially distended, and the popliteal space 

much filled up, while the parts on each side of the patella normally depressed 

were projecting. Measurement gave — 




Fio. 17. — Hydarthrus of 
ie. (B. W.) 



Normal knee. Diseased knee. 

Above patella 13 inches. 17 inches. 

Across " 13|- " 15| " 

Below " Hi " 12f " 

1 In another more recent case, the same sort of tissue was only from J to nearly f . 
inch thick. 



168 DISEASES OF THE JOINTS. 

Very remarkable was this tumefaction in conjunction with entire ab- 
sence of inflammatory symptoms. The man was too ill to rise from his bed, 
but he assured me that when he had walked he suffered very little or no 
pain, but only from considerable weakness of the joint and of the limb. 
The disease had commenced about four years ago, when he fell and received 
a blow on the knee. He suffered the symptoms of acute synovitis, but con- 
tinued his employment for four or five days ; he then was obliged to he 
up for more than a week. His knee got better, yet never regained its 
usual size or strength, and since then had gradually swollen to the above 
size, and had remained much the same for the last year and a half. Nine 
days after I had seen this patient he died of the pyloric disease and of maras- 
mus, and I had an opportunity of examining the joint. The cavity was 
drained through a canula, 9£ ounces of fluid being withdrawn ; after open- 
ing the joint 2£ ounces more were obtained. Some of this fluid, boiled in 
an evaporating saucer, became so solid that when the vessel was inverted 
only two or three drops flowed away : it contained, therefore, a large quantity 
of albumen. The mucin was in stnaller proportion than the norm, for the 
liquor was not thready, though it still possessed the natural lubricating feel. 
A sample placed in a conical glass deposited in twenty-four hours an abun- 
dance of endothelial cells and leucocytes, exudation corpuscles, a few lumps 
of gelatinous concreta, and several shreds, which were probably broken 
portions of hypertrophied fringes. 

The inner or free surface of the synovial membrane was greatly con- 
gested, of a darkish purple hue, and was very rough, exhibiting in parts a 
surface not unlike lichen, while in other portions the enlarged ends were 
clubbed ; the nodules, of the consistency of bladders, containing fluid — in 

one or two instances soft, gelatinous 
conglomata of cells and nuclei or of oil. 
The accompanying sketch of a piece laid 
in water was made. This form of rough- 
ness was marked along the cartilage- 
zone, especially of the inner tibial tuber- 
osity, but was most evident above the 
patella, and in that part of the subcru- 
real sac where the membrane reflected 
from the bone forms the end or cul of 
the sac. At this point was a shred of 
-Hypertrophied fringes seen under new membrane, irregularly oval in shape, 

| of an inch long, and in its broadest 
part not quite £ inch wide. It was thickest about two-thirds of its length 
from the narrowest end, namely, about T 3 j- of an inch, and at this part over 
a surface 3 lines in length and 2 in width. It was organically united .to the 
synovial structure, two or three vessels passing into it immediately break- 
ing up into a leash of twigs and becoming lost in its structure. The rest 
was loose, consisting of very lax fibrous tissue containing a jelly-like sub- 
stance, composed of corpuscles united together by structureless material. 
Surrounding the whole synovial membrane was a dense, white tendon. The 
structure very hard, and so resisting that the opened and emptied cavity 
did not collapse, but remained patent and gaping. The section edge at 
different parts showed this white material to be of very variable thickness. 
It was lined with the thickened synovial structure, of a yellow color, in 
places lighter, in places darker in hue, and of a gelatinous consistence, vary- 
ing from ^ to £ inch, and soaked in the same fluid as filled the cavity of the 
joint. Microscopic examination of the tendon-like structure showed it to 




HYDARTHROSIS OR HYDROPS ARTICULI. 169 

•consist of condensed areolar tissue, almost entirely of the white elements 
The jelly-like substance was composed chiefly of yellow fibrous tissue, wide- 
meshed, rarefied rather than condensed ; the interlacements exhibiting 
plentiful connective-tissue corpuscles, the interstices crowded with cells. 

These cases have been selected from others, as showing well the state 
of parts in different instances. Cases XLV. and XL VI. are of the same 
form of disease, the one only older and more developed than the other. 
Case XLVII. is of a somewhat different variety, related, though perhaps 
only distantly, to a malady (multiple false bodies) to be described in the 
sequel. 

The former more passive form of disease usually follows an acute syno- 
"vitis, especially if the primary attack occur in persons whose debilitated 
constitutions do not permit the vessels distended, by inflammatory acts, to 
recover their tone. Nevertheless, it must not be supposed that even this 
most passive accumulation of fluid is due to mere exudation, such as occurs 
in oedema or in hepatic ascites. It is to be remarked' that passive oedema, 
however largely it may affect the areolar tissues, spares the joints. Fem- 
oral, or ilio-femoral aneurism, frequently produces, by pressure on the 
neighboring vein, oedema of the thigh and leg ; yet, although I have care- 
fully looked for hydarthrosis in every such case that I have seen, that articu- 
lar complication has never been present. Again, the fluid of dropsy, prop- 
perly so-called, is entirely different to that of hydarthrosis ; this latter 
contains a great deal more albumen in which it resembles the fluid of 
hydrocele. Mucin, though in smaller relative proportion than in normal 
synovia, is also present, which differentiates it from hydrocele liquor ; a 
brownish hue of more or less intensity is usual in the fluid of such cases as 
have commenced in an acute synovitis, especially if that primary attack 
have been traumatic (blood-staining). 

A point well deserving attention is the presence of a fibrinous concre- 
tion, -adhering by a small part of its area to the synovial membrane ; a con- 
dition which, though not constant, is very frequent in hydarthrosis, and 
more particularly I have reason ' to believe in cases commencing in acute 
disease. As we shall see immediately, the primarily chronic hydrops ar- 
"ticuli exhibits either no inflammatory symptoms, or such slight ones that 
any idea of a fibrinous exudation may probably be excluded, while such 
action is a not unfrequent accompaniment of acute synovitis ; the effused 
fibrin may either remain on the membrane, or, becoming at first mingled 
-with the ordinary joint fluid, may afterward consolidate, and by subsidence 
attach itself to some portion of the synovial surface (see p. 31). *In these 
■circumstances is contained the explanation of a great difficulty we occasion- 
ally encounter in procuring entire resolution of an acute synovitic effusion, 
even after inflammatory symptoms have been subdued ; also of a residual 
pain and tenderness distinctly localized in certain unusual and in different 
cases varying spots. Here too lies the etiology of a slowly increasing dropsy 
of the joint, which occasionally begins to affect patients even months after 
an acute synovitis has been apparently cured. This view gains additional 
support from the fact that the presence of a loose body, even a mere soft 
lipoma, always produces, after a time, even if it cause no inflammation, a 
dropsical condition of the joint. 

The form of hydarthrus, which commences without previous or accom- 
panying inflammation, and is not attended by any marked change of struc- 



' See an examination by Bonnet, Maladies des articulations, tome i. , p. 430. 



170 DISEASES OF THE' JOINTS. 

ture, villous proliferation or the production of false bodies, is of so extremely- 
difficult etiology that I would rather not speculate on its causes, but will be 
content with the facts that it does not arise like oedema from venous pres- 
sure, that it is not intimately connected with rheumatic or other constitu- 
tional diathesis, and is therefore mon-articular, although I have observed 
in cases of long standing a tendency of the same joint on the other side to- 
participate. 

The form of hydarthrosis connected with dendritic growth and produc- 
tion of false bodies is so far discussed in Chapter IX. that only a few words, 
are here necessary, more especially since the mere presence of more or less, 
fluid is in such cases of secondary importance. Primary chronic dendritic 
fringe hypertrophy is one of the appearances met with in arthritis defor- 
mans, and this fact has led to the idea that hydarthrosis with such growth 
is always the commencement of that most obstinate malady. I believe this 
to be an entirely false notion, although doubtless many cases of arthritis 
deformans have in their earlier stages impressed the surgeon as synovitis, 
with dropsy, etc., before exhibiting their true character. The sort of 
malady now under consideration is generally connected with the rheumatic 
diathesis, is almost confined to the knee, occasionally attacks the elbow, and 
is most common with persons whose avocations oblige them to work on the 
knees, and to expose those joints to cold and damp. It is of more inflam- 
matory origin than the simple form, is more painful, and leads more quickly, 
i.e., without the presence of so much fluid, to uselessness, or greatly re- 
stricted usefulness of the joint. The bodies, which the tuft ends enclose, 
are, occasionally, merely lipomatous, the fat, kept warm in the joint-cavity, 
has the consistence of oil. The bodjes themselves, if extracted during life, 
look like oil-drops enclosed in a translucent capsule, indeed, this is what 
they really are ; but exposed to the cooler air, the fat consolidates, and the 
little bodies harden slightly — of such there may be hundreds in a single- 
joint,' — varying from the size of a mustard-seed to that of a black currant. 
Closely connected with this condition, is the presence of innumerable small,, 
almost transparent, floating motes, looking like pieces of jelly. They are 
common in the dropsy of tendinous sheaths, less so in joints, and are formed 
by pullulation of those secondary sacculi of the fringes previously described 
(p. 12), which thus enlarged break from their fragile connection. Some- 
times, however, the fringe ends contain nodules of cartilage, even of bone, 
a condition which places the malady in another category. 

In either form of the disease, plates of cartilage or of fibro-cartilage are 
occasionally developed in the thickness of the hypertrophied subsynovial 
tissue. When of the latter material they enclose in wide meshes a good 
deal of fat ; when of the former they sometimes become ossified : they are 
of the structure described in Chapter IX., and are probably formed in the 
same way. 

These changes are associated with a commensurate hypertrophy of the 
peri-synovial tissues, which become thickened and condensed into a tendon- 
like or ligamentous material, simulating in places fibro-cartilage ; indeed, 
but this is more common in the cases combined with fringe hypertrophy 
and the formation of false bodies, plates of true . cartilage may form a part 
of the abnormal wall. This enlargement is in simple hydarthrus due to 
the mechanical force of greatly augmented fluid, and to the hyperplasia 
following increased strain necessary to resist its pressure. In tie latter 

1 Compare (Chapter XVII. ) the melon-seed or hydatiform bodies found in inflamed, 
tendinous sheaths. 



HYDARTHROSIS' OR HYDROPS ARTICULI. 



171 



more constitutional variety, vice of diathesis, probably the rheumatic, is in- 
timately concerned in the morbid irritation. 

From the mechanical action of the excessive fluid result also elongation 
and stretching of the ligaments, which cause such relaxation of the joint, 
that hereon its useless condition in very great part depends. A knee which 
has been long thus diseased may be bent sideways, or the tibia may be ro- 
tated on the femur, a sixth of the circle to the right and left ; also — and 
this is of diagnostic value — the lower bone may be moved laterally on the 
condyles a considerable distance, generally with a smooth, i.e., non-crepitat- 
ing, motion. 

After an interval, greater in the simple, smaller in the dendritic form of 
disease, the cartilages undergo fibrillation. At first, they simply lose their 
opalescence, become striated, the corpuscles slowly break up, fatty degen- 
eration of the cells sets in, and then the hyaline structure splits into fibres 
(like velvet pile), some of which loosen themselves from the articular lamella, 
and are floated away by the joint fluid. In one case that I examined, the 
whole structure had become very 
thin, and fibrillation appeared 
only in a few spots, but this was 
in the person of a man, aged 
seventy-eight, and the appear- 
ance was probably not entirely 
due to disease. 

Occasionally, though rarely, 
in connection with joints thus 
diseased, cysts are formed, or at 
least are distended, in its imme- 
diate neighborhood ; they are 
most commonly found in the 
popliteal space, or upper and in- 
ner part of the calf, and are 
formed by protrusion, a sort of 
hernia of the synovial membrane 
through one of the apertures of 
the posterior ligament. Such oc- 
currence is most likely to take 
place in very slow gradual disten- 
tion of the membrane, but may 
also arise in less chronic mala- 
dies, and of course is more likely to take place if the patient be kept on his 
back. The protrusion having once been formed will go on increasing, 
even though the joint-effusion diminish and disappear. The process by 
which such hemia-like cysts are formed is precisely similar to one mode of 
the production of ganglia from a joint or tendinous sheath, and in the same 
way the connecting tube between the new cavity and the normal one may 
be obliterated. All surgeons should be aware that such cysts about the 
popliteal space, or upper part of the leg, may communicate with the interior 
of the knee-joint, since, if taken for an abscess and opened to the air, the 
gravest results may follow. 1 

Symptoms. — The especial characteristic of hydarthrus is the presence of 
a large fluid swelling within the cavity of the joint, combined with the ab- 




(enlargement of eubcrureal 



1 See Chapter XVII. and an excellent paper by Mr. Morrant Baker in the St. Bar- 
tholomew's Hospital Reports, vol. xiii. 



172 DISEASES OP THE JOINTS. 

sence of any inflammatory symptoms. There only remains then, the non- 
existence of these latter being distinctly recognized, to ascertain with ac- 
curacy the fact that the swelling is due to fluid, and that the fluid is within 
the joint-cavity. The symptoms of liquid in different articulations have been 
given with sufficient minuteness (Chapter EL) ; the great quantity of effu- 
sion in this disease renders its diagnosis only more easy. Yet the form of 
the swelling itself differs somewhat from that of an acute synovitis, inas- 
much as the slower accumulation endows it with greater power of distend- 
ing and enlarging those parts of the joint-sac which are least supported by 
ligamentous or other firm bands ; the joint therefore assumes an uneven 
and " nubbly " aspect. 

Thus at the knee, the parts at each side of the ligamentum patellae pro- 
ject in a very conspicuous manner ; while — and this is a marked diagnostic 
sign — the subcrureal pouch of the membrane is more particularly enlarged, 
being not only protuberant but encroaching abnormally far up the femur. 
JBy pressing, while the knee is straight, on this pouch, with the flat hand, 
one may force the fluid from it into other parts, for instance, into the already 
distended portions by the side of the patellar ligament, which then visibly 
increase, and again when the hand is removed diminish. Thus the surgeon 
may actually make fluctuation visible. The peculiar symptom which I have 
named knocking of the patella is in these cases very plainly marked. In 
most cases the popliteal space is almost obliterated, more rarely it becomes 
—and of course only when ligaments are yielding to the internal pressure — 
an absolute swelling. 

At the elbow, where the disease is next in frequency to the knee, the 
swelling is chiefly over the internal condyle, but it also runs up the back of 
-the arm, pushing backward the triceps tendon, and forming on each side of 
it a large cushion-like swelling. In cases of long standing, the sigmoid 
notch of the ulna becomes slightly separated from the condyles of the hu- 
merus, and there will arise that knocking or elasticity of the olecranon which 
I have denied to be a usual symptom either of acute or of strumous syno- 
vitis. This condition of joint is accompanied by a certain amount of stiff- 
ness, often also by a dull sense of distention and weight. The stiffness 
seems due to two causes : to increased tension of the capsule, and to the fact 
that the limb naturally seeks that position, which allows most room to the 
fluid. 

Hydarthrosis of the shoulder-joint is rare. A case which I studied with 
•care exhibited the following peculiarities thirteen months after pain and 
-weakness of the limb were first observed. The arm hung by the side from 
the shoulder to the elbow ; this latter joint was bent at a right angle, and if 
the hand was not supported in a sling or on a table the patient held it in 
the other, as a depending posture caused pain about the front of the shoulder. 
The joint was greatly enlarged, so that the acromion formed a depression at 
the top of the swelling. The enlargement was divided into three parts by 
broad, shallow sulci ; one corresponding to the anterior, the other to the 
posterior axillary fold. The chief enlargement was outside the arm and 
under the deltoid ; but the axilla was nearly completely filled up and the 
swelling encroached behind on the scapula, half the length of the infra- 
spinous fossa. Measurement with a pair of long callipers showed the arm 
to be \ inch longer than the other ; this was produced by relaxation of the 
ligaments and of the deltoid, which allowed the limb to drop ; for on holding 
the arm about the middle and moving it briskly upward I could cause the 
head of the humerus to tap against the glenoid cavity and produce a sense 
exactly like " the knocking of the patella." The patient had almost com- 



HYDARTHROSIS OR HYDROPS ARTICULI. 173 

pletely lost the power of raising the arm from the side ; he could bring it 
a little forward and in front of the chest, and had more power to place it 
behind The pain was not severe, but was a constant, dull, heavy aching. 
Fluctuation was markedly evident throughout. 1 • 

It is hardly necessary to describe here the peculiar shape of the enlarge- 
ment produced by this disease at other joints, since it is, until the liga- 
ments are almost destroyed, very similar to that produced by acute or sub- 
acute sero-synovitis. 

When the malady is of old standing, and the secretion in the joint is ex- 
cessive, the ligaments become so stretched as to be of little or no use as 
bonds between the bones. In the worst cases they may be simply spread 
out, and merged into that inflated white structure which surrounds the 
joint, and is formed by metamorphosis from the peri-synovial tissue. Hence 
result looseness and flaccidity of joint, rendering the limb almost valueless, 
as in a case under the care of my friend Mr. Bellamy, in which the tibia 
was movable in all directions on the femur. 

Thus the mere diagnosis of large fluid-accumulation in a joint which is 
not, to say the least, the subject of acute, nor indeed of subacute, inflam- 
mation, presents no difficulties. But we have, under the name hydarthrus, 
to do with different forms of disease having this one condition, fluid dis- 
tention of the joint-sac, in common. Now in some of those forms that dis- 
tention is a mere adjunct to more profound changes ; in others, it is the 
chief and primary evil. The diagnosis, to be of any value as the foundation 
of prognosis and treatment, must distinguish these varieties of disease. 
Occasionally, we see cases so early, that this task is very easy, the facility 
depending on the comparatively small amount of effusion, which enables 
the touch to distinguish the presence of hypertrophied fringes, even though 
not largely developed. They are most easily detected by placing two or three 
finger-tips on a part of the synovial membrane, which is most superficial 
as well as considerably distended, making sufficient deep pressure to bring 
its inner surface in contact with the underlying bone, and then to move the 
whole mass of the soft parts up and down upon the hard substratum. Un- 
der such manipulation hypertrophied fringes, roughening the inner syno- 
vial surface, impart to the hand a rustling sensation, which, if we may use 
terms applicable to the ear as descriptive of tactile impressions, we may call 
a bruit parchemine. I have long ago compared it to the sensation produced 
by rubbing between the fingers two surfaces of a silk ribbon, calling it in 
my class " silken crepitus." A fine silk will represent but slight hypertrophy, 
a rougher one more considerable enlargement, a ribbed ribbon will simu- 
late a nodulated dendritic growth. In some cases, if the joint be super- 
ficial, we may even make out grains or knots movable within certain limits ; 
these are the nodules of enlarged fringes. Occasionally, on examining a 
joint, the hands making the tide of fluctuation pass from place to place, 
will feel not the wave merely, but the stream ; a sense of movement, of pro- 
gression is imparted to them. This is produced by the presence of those 
small detached solids or semi-solids already described (p. 170). I have 
indeed, after detecting this symptom pretty early, felt it in subsequent 
stages manifestly increase as the bodies augmented in number. 

But if the joint be much distended, it becomes impossible to press the 

1 Some of these symptoms differ slightly from Moris. Roux's well-known case, 
"Mem de l'academie," torn. xiii. He founds on his observations some distinctions be- 
tween hydarthrosis of ball and socket, and of hinge-joints, saying that in the former but 
not in the latter, neighboring prolonga tions of synovial membrane participate. As we 
have jr » ^=^= ~ ~" ~ 



174 DISEASES OF THE JOINTS. 

synovial membrane sufficiently against the bone to produce the silken crep- 
itus ; hence inability to procure such evidence must not cause us to con- 
clude on the absence of enlarged fringes. Before any judgment on this 
point can be formed, the. cavity must be emptied, partially or entirely, when 
the silken crepitus, previously absent, will, if the villi be hypertrophic, 
appear. 

The evacuated fluid should also be utilized to assist our judgment. The 
presence of melon-seed bodies, a very thick, almost viscous fluid, with large 
concreta, and if a full-sized canula have been used, perhaps a detached 
nodule or two, indicate considerable changes. A fluid, rather thinner than 
synovia, pale and yellow, denotes but slight changes. In all kinds of the 
liquor, but chiefly in the viscid, a plentiful deposit of cells is rather indi- 
cative of extensive morbid alterations. But another condition, namely, the 
existence of fibrous or fibro-cartilaginous plates in the peri-synovial tissues, 
may generally be best and most clearly made out, while the joint is still 
considerably distended and semi-tense, they present themselves to the 
erudite touch as more or less rounded or flattened projections floating on 
the subjacent fluid ; they can be depressed inward toward the cavity, but 
not moved from side to side. They dance, therefore, on the fluid, whose 
fluctuation can be felt through them, dulled more or less according to the 
thickness and resistance of these plates. 

Evident and rough silken crepitus, presence of nodules and of cartila- 
ginous peri-synovial plates, indicate some other form of disease than sim r 
pie joint-dropsy. Perhaps the condition will tend to the formation of muV 
tiple false bodies with persistent distention of the joint. Or, again, this 
condition of synovial membrane may be only the first phase of arthritis 
deformans. To make this distinction the surgeon must very fully study 
the shape of the bone-ends, and ascertain the presence or absence of osteo- 
phytes and of bony crepitus. 

The prognosis must depend on the class of case, on the antiquity of the 
disease, and on the constitution of the patient. Simple hydarthrosis, with 
but little change of synovial tissue, may be overcome, and the joint restored 
to fair usefulness, if the ligaments be not too much relaxed. Great disten- 
tion of those parts is a serious obstacle to cure, and a greatly loosened joint 
can only become restored, if ever, after a considerable time. 

When considerable change of structure has taken place, less favorable 
results are usually obtained ; yet, if the fringe hypertrophy result only in 
the production of small tufts and small lipomatous false bodies, a useful 
joint may yet be secured. Larger and many bodies, with fibrous or car- 
tilaginous peri-synovial plates, indicate a less favorable — greatly enlarged 
and roughened bones the most unfavorable — state of affairs. 

Treatment. — After an attack of acute synovitis, simple surplus of fluid in 
a joint-cavity may be either merely the relic of a past, or may be the com- 
mencement of a future disease. If the former, it will either remain station- 
ary, or will decrease ; if the latter, the contrary event will occur. A strong 
opinion was expressed (p. 35) that if the effusion of an acute synovitis be 
evacuated and not too late in the disease, subsequent weakness of the joint, 
enlargement of the synovial cavity, and, a fortiori, the tendency to hydar- 
thrus, are to a very large extent avoided. We may go further ; if, after the 
inflammatory phase of acute synovitis has entirely ceased, there yet remain 
a considerable amount of fluid in the joint, its very presence will tend to 
injurious distention. On the surgeon's judgment, as to whether the effu- 
sion is becoming, or is capable of being absorbed, will depend his choice 
whether he will use further remedies, both general and local 



HTD ARTHROSIS OR HYDROPS ARTICULI. 175 

We must, in using the former, be careful clearly to formulate to our- 
selves what we aim at, and what it may be possible to do. A physician 
may, in many cases of cedema about the lower limbs, decrease, even entirely 
eliminate, the fluid effusion by means of purges and diuretics, mercury, 
etc. We shall never succeed in doing this for a hydarthrus, it is not 
cedema, and does not arise in the same way, nor from like causes ; we 
might, therefore, almost drain from the rest of the body all fluids, and yet 
the joint-bag — since deficiency of excretion has nothing to do with the dis- 
ease — would remain full. One should, therefore, promote neither purging 
nor diuresis, on the mere chance of getting some of the synovial fluid ab- 
sorbed, unless the alvine or renal functions be faulty. 

On the other hand, if there be reason to believe in a rheumatic condi- 
. tion, iodide of potass, James's powder, ipecacuanha, guaiacum — probably 
also salicine or its derivatives — may be prescribed. Antimony was forty 
years ago much lauded by M. Gemelle, and had a certain vogue. 1 I re- 
ported indeed a case cured by that medicine, in combination, be it remarked, 
with local measures, but the remedy has not maintained its reputation, and 
to keep a patient nauseated for nearly a fortnight is severe treatment, unless 
cure of the disease were certain. 

The Local Remedies are manifold. Rest, especially if the patient have 
previously been walking about freely, causes almost always a certain dim- 
inution in the size of the tumor. Strong rubbing upward is often of con- 
siderable assistance, and pressure firmly applied has more than once in my 
hands proved curative. The best method of using it is by means of elastic 
webbing tightly bandaged over the joint, while the part below is supported, 
to prevent swelling, by an ordinary linen or cotton roller. Blisters, iodine 
paint, strong stimulating lotions, have all been used, with occasional advan- 
tage. The iodide of lead and potass ointment may also be useful. Mer- 
cury in any form appears to be injurious. It must be observed of all these 
applications that while the patient is in bed they seem to do good, the 
swelling may diminish, or almost disappear ; but when the patient gets 
about again, hypersecretion is very apt to recommence ; the old disease to 
reappear. The best means of preventing recurrence is pressure, but even 
this w\ll sometimes fail. 

While we may thus cure a case of rather slight hydarthrus of not too 
old a date, we can hardly hope by the above means to overcome the dis- 
ease if it be more severe. Such cases, and indeed slight recent attacks, if 
not rapidly yielding, should be more efficaciously dealt with, lest worse 
follow. 

Puncture of the Joint, and evacuation of the fluid, will, at all events for 
the time, diminish the tumor, and enable pressure to act more directly on 
the membrane. The surgeon should seize the opportunity of making the 
thorough examination already recommended (p. 173), then the compressing 
bandage should be applied at once. It will certainly cause a fresh flow 
through the puncture-wound, even though very valvular ; hence that part 
should be covered last, and the protective material, a piece of carbolized 
oil-silk is the best, merely laid on beneath the last turn of the bandage. 
The sort of fluid withdrawn should be carefully examined, with a view to 
guide more accurate diagnosis. 

If these means fail, and if absence of false bodies and osteophytes have 

' Memoires de l'academie, July, 1840. Mons. Gemelle began with half-grain 
doses every three hours, incresising them till they amounted to twelve grains in the 
twant.v-fmir hnnra | fly* maH^caJaaa-hai—— ntinnnd about twelve days. 



176 DISEASES OF THE JOINTS. 

been verified, the joint may be injected with iodine. To do this a trocar, 
with a canula whose perfect fit upon the nozzle of a syringe has been 
tested, is introduced into the articulation ; all the fluid is evacuated, pres- 
sure by the hand in different directions ensuring as complete emptiness of 
the joint as possible. The syringe, previously filled with the solution (one 
or even two drachms of tincture of iodine to the ounce of water), is adapted, 
and the fluid injected. For the knee, from four to six, for the elbow or 
shoulder about two ounces, usually suffices ; but if distention have been 
considerable, double these quantities may be necessary ; indeed, I prefer 
to try and inject as much fluid as has previously been drawn off. "When 
enough of the solution has been passed in, the syringe withdrawn, and the 
canula mouth occluded (a short piece of wax urethral bougie is the most 
convenient plug), the joint should be kneaded with the hand, placed in 
various positions, the limb raised, depressed, turned, etc., until one is sure 
that every point of the membrane has been- washed by the injection ; then 
the limb is to be so placed, that the canula lies at the most dependent 
part, and all the fluid is to be withdrawn. It is impossible to state any 
definite time during which the injection is to remain in the joint-sac. In 
my experience, between two and six minutes is sufficient to produce that 
sense of heat in the joint, with slight aching up the limb, which must be 
the signal for the withdrawal. 

Subcutaneous incision of the membrane is in this disease, as in acute 
synovitis, often valuable. It is performed in the way described at p. 37. 
The method was first introduced by M. Goyrand ; it is simple, all but pain- 
less, and in uncomplicated cases fairly successful. The incision should, 
however, be wide ; indeed I prefer two, opposite each other, on either sides 
of the joint. When, in two days, all the fluid has left the synovial cavity, 
and infiltrated the neighboring parts, firm pressure should be used, and 
some endeavor be made, if the tumefaction have been considerable, to fold 
one edge of the synovial incisions over the other, and thus at once restrict 
the size of the sac. The method is founded on treatment of the most 
prominent symptom, yet is successful when only slight changes of the 
synovial membrane have taken place. 1 

Free Incision into the joint could not, some few years ago, have been 
too strongly condemned ; but since the introduction of antiseplicism a 
different view must be taken. I have cured more than one obstinate 
hydarthrus, with several fringe hypertrophies, by this means, namely, a 
sufficiently wide incision to permit all the fluid to come away at once. If 
pendulous fringes exist, and the place of incision have been well chosen, 
one or more of these will float out and may be removed. The joint may 
then be squeezed and kneaded in the hands, when more nodules will prob- 
ably appear. If so, the finger, previously dipped in carbolic acid solution, 
may be carefully introduced, any soft false body that may be felt drawn to 
the surface or broken away, and allowed to flow out. India-rubber tubing 
may be then oiled (carbohzed oil), passed well into the cavity, and with a 
large syringe a strong stream injected. Such treatment, apparently very 
heroic, is by no means dangerous, and is very efficacious. Of course the 
wound must be dressed antiseptically, and the limb, for about three weeks, 
placed on a splint, which can be arranged at different angles. 



1 M. Bonnet's Maladies des articulations, tome i., p. 434, relates a curious instance 
of rupture of the distended synovial membrane by a fall, whereby a hydarthrus of 
some standing was at once cured. 



HYDARTHROSIS OR HYDROPS ARTICULI. 177 

Case XLVHI. — Susan B., aged forty-eight, came among my out-pa-* 
tients at the Charing Cross Hospital, April 13, 1860, with a swollen knee. 

The right knee had been painful for about a week ; the pain had come 
on at night ; it was somewhat swollen : the tumor was fluctuating ; the 
patella not in contact with the femoral condyles : slight stiffness, no tender- 
ness, heat, nor redness ; she was subject to rheumatic pains, chiefly in 
the right shoulder, and attributed the pain in the knee to rheumatism ; she 
is strong and stout : knee to be strapped. 

She was ordered half a grain of tartrated antimony with nitric ether 
three times a day. % 

April 17th. — Knee perhaps a little smaller : reapply strapping. 

April 24th. — -The knee is certainly better ; the swelling had much de- 
creased : knee to be strapped with the emplastrum ammoniaci. 

May 5th. — The medicine produced some feverish symptoms and diar- 
rhoea. To be discontinued ; some Dover's powder and an alkaline mixture 
were ordered. 

May 12th. — The diarrhoea and feverish symptoms subsided ; the knee 
had quite regained its shape ; there was a little thickening above the 
patella : to be strapped again with the same plaster. Ordered to take two 
grains of quinine, in the form of pill, three times a day. 

May 19th. — Discharged ; cured. Ordered to keep the knee strapped. 

This patient returned to me more than four years (May 7, 1864) after 
her discharge, with a return of the swelling, but very considerably exagge- 
rated. She told me that the cure which I had effected had only lasted 
about three months, and that then the knee began slightly to swell again. 
She often had to be at home in hospital or infirmaries, she now wished the 
leg to be removed. I proposed first to use some other means. 

May 14th. — Tapped knee— drew off nine ounces of a rather thin, straw- 
colored synovia — injected nine ounces of solution of iodine, two ounces in 
pint, after four minutes she felt some pain up the thigh — only a little more 
than eight ounces of the fluid came away, no more in any position of the 
limb would flow. Joint enveloped in elastic web bandage and placed on a 
Maclntyre splint. 

May 16th. — Had some pain, which indeed on the night of the operation 
was rather severe, but she slept pretty well ; knee rather swollen — puffy. 

May 20th. — No pain, except at night. On trying to move joint some 
paiif was caused, and there was some stiffness. 

May 28th. — Pressure, rubbing and passive movement were used. Since 
the last report the knee seemed quite well, save slight restriction of move- 
ment. 

I saw this patient three years after the operation, the knee was still 
quite well, and she said as strong as the other. 

Case XLIX. — Elizabeth Grant, aged twenty-eight, a tall woman with 
powerfully formed limbs, came among my out-patients to the Charing 
Cross Hospital, January 8, 1858, for an enlargement of the right knee. 

■ Six months ago, in doing some household work, she knelt upon a 
thimble and hurt her knee. It was painful and swollen for three weeks ; 
she rested as much as she could, but underwent no treatment : at the end 
of that period both the swelling and pain disappeared, and she took no 
further notice of the occurrence ; but, ten days ago, the joint began to ' 
swell again and to be painful. She had been suckling up to the above 
date : the child being fourteen months old. 

The knee was very considerably swollen, presenting a baggy tumefac- 
tion, concealing the shape of the bones, and larger in some places than 



178 DISEASES OF THE JOINTS. 

• others ; one of these was in the lower part of the joint on either side of the 
ligamentum patellae ; but the chief enlargement was on each side of the 
rectus muscle. The measurements are : 

Sound. Morbid. 

Above patella 15£ inches. 17£ inches. 

Across " 15i " 17 

Below " 13£ " 15i " 

The tumor was fluctuating ; waves of fluid could be made to pass frpm 
one part of the joint to the other ; there was some appreciable thickening 
of the peri-articular tissues ; the joint was neither tender, hot, nor red ; 
she had very little pain, but some stiffness ; she could in the morning walk 
without any limping, but in the evening, and when she had been about a 
good deal, she had a sensation of " bursting " in the joint, increased stiff- 
ness, and was obliged to limp. 

I ordered her to wean her child : to have a gutta-percha splint bound 
to the back of the joint ; a blister across lower part of the femur, three 
grains of iodide of potass. 

January 13th. — She said that she was obliged to do her work ; the 
splint prevented this, and therefore she took it off: there was no improve- 
ment : blister to lower part of joint. 

January 18th. — She was no better : I persuaded her to come into the 
house, and Mr. Canton kindly allowed her to remain under my care. Ke- 
peat the blister above the joint, and let it be kept open with iodide of 
potass ointment : bed. 

January 27th.— She was not at all improved : let the blister heaL 

February 3d. — The blister having healed I passed a narrow tenotome 
into the joint, about an inch and a half above the outer edge of the patella, 
and sweeping the blade upward, divided the synovial membrane to an ex- 
tent of about an inch and a half to two inches, and bandaged the knee 
tightly from below upward. 

February 5th. — She was in no pain : the bandage was quite loose ; when 
it was removed the joint was found reduced ; there was still a good deal 
of swelling, but it was diffused and did not fluctuate : bandage reapplied. 
To take quinine and iron. 

February 12th. — The knee was strapped three days ago ; she was in no 
pain ; allowed to get up. 

February 23d. — There was no appearance of return, but the knee has 
been kept strapped ; discharged. 

I saw this patient, casually, on April 8, 1859 ; she had had no return of 
swelling, and had no inconvenience with the knee. 

Case L. — James F, aged forty-nine, came under my care into Charing 
Cross Hospital with a hydarthrosis of the left knee, May 6, 1875. I 
treated him with subcutaneous incision without result. I injected the joint 
with iodine, but with only temporary benefit. He had been discharged, 
but returned, for as soon as the man got about again the disease returned. 

January 5, 1876. — Under chloroform narcosis I made a free incision, 
observing all antiseptic precautions, into the joint on the inner side. As 
far as could be estimated about ten ounces of opalescent fluid, containing 
many melon-seed bodies and glomeruli, came away. Passing my finger in 
I found a rough hirsute inner surface to the membrane. Injected the 
cavity with a three per cent, solution of carbolic acid, placed a drainage- 
tube in the lips of the wound, so that its end should just project within 



HYDARTHROSIS OR HYDROPS ARTICULI. 179 

the synovial cavity — dressed him antiseptically, and placed the limb on a 
splint. 

January 8th. — No temperature or other bad symptom. A great quan- 
tity of fluid flowed constantly away, necessitating the introduction of a 
mass of tenax under the last turn of the roller. 

February 8th. — There had been no bad symptom. I directed the splint 
to be removed twice in the week and the joint moved ; it produced no pain 
unless the motion were carried beyond a certain point ; the arc was much 
restricted. The discharge of fluid had gradually decreased, and was at the 
t above date very slight ; pressure with an elastic bandage since first of the 
month. 

March 8th. — The wound healed entirely. About February 26th, the 
joint was greatly decreased in size ; some silken crepitus could be detected. 
Discharged, with orders to keep up pressure. The limb could not be quite 
straightened, and only flexed to about an angle of 130°, but was quite 
available for all ordinary uses. 



CHAPTEE IX. 

ON MOVABLE BODIES IN JOINTS. 

The presence within the joints of movable loose bodies has been only 
known to surgeons since the time of Ambrose Pare, who, in the year 1558, 
opened an " apostbume " in the knee-joint of a barber, and evacuated with 
the fluid a loose cartilage. Since his time the bodies have been known by 
the name " loose cartilage," but inasmuch as movable bodies in joints may 
also be either bony, fibrinous, or lipomatous, it will be well to avoid any 
term for the general malady that shall denote a structure in itself so vari- 
ous. The essential of the condition, considered clinically and simply stated, 
is that the joint-cavity contains one or more movable masses of variable 
size, which often give rise to troublesome symptoms. Such body may be 
either cartilaginous, osseous, or a mixture of the two, fibrous or fibroma- 
tous, mere lipomatous growths, or may in part be made up of a foreign 
substance introduced from without. The cartilage, unless the movable 
substance have once formed a normal portion of the joint, is not, like ar- 
ticular cartilage, provided with corpuscles ; the characteristic cells, often 
very few in number, are simply scattered irregularly through the substance. 
Sometimes the centre of such body consists of a yellow, thick jelly, like 
inspissated synovia. Neither does the bony loose body consist of regularly 
formed bone with its various anatomical constituents. Certain of those 
which have been examined were possessed of well-formed lacunae with 
canahculae ; others of abortive lacunse, without those appendages ; Haversian 
canals are always absent. More commonly the structure is not osseous at 
all, but a mere amorphous or granular mass of lime-salts. "When the body 
is a mixture of some such bone and of cartilage, the greatest variety in their 
relative position obtains ; the one or the other may form the circumference 
or centre of the globular or ovoid shape. In the plate-like variety the one 
surface may be cartilage, the other osseous, or the two kinds of structure 
may be irregularly intermixed or tesselated ; occasionally the one may per- 
meate the other in an arborescent manner. 

These bodies are often multiple. I have removed three from one knee- 
joint (see Case LIV.), and have seen in an elbow a number which I should 
compute at between thirty and forty (see Case LI). Mr. Berry, of Kentucky, 
is stated by Pirrie' to have removed from the knee of a negro thirty-eight 
such bodies ; moreover, very small fatty nodules at the end of hypertrophied 
fringes may be innumerable. 

In size they vary from the scarcely visible to the bigness of a horse- 
chestnut, or even larger. In shape they have a tendency to four forms : 

1. Oval or circular plates, either bi-concave, concavo-convex, or bi-convex. 

2. Globular, oval, or chestnut-shaped. 3. Conglobate or mulberry. 4 Pyr- 



1 Principles and Practice of Surgery, third edition, p. 343. 



ON MOVABLE BODIES IN JOINTS. 181 

iform. These two last forms are rare ; the third shape is in part or en- 
tirely osseous ; the last lipomatous. 

The predilection of these bodies for the knee is remarkable. I should 
say that nine-tenths of the cases occur in that joint, next in order of fre- 
quency is the elbow. The hip becomes the habitat only, I believe, in ar- 
thritis deformans ; one is said to have been found in the temporo-maxillary 
articulation. Operative measures for the removal of such bodies have 
never, as far as I know, been resorted to at the hip, only occasionally at the 
elbow ; far more often at the knee. 

Although it would not be warrantable to assert that all false bodies in 
joints are due to the rheumatic diathesis, yet it is certain that many single 
ones (save the lipomatous), unless arising in injury, are most commonly 
found in persons of such constitution. The multiple ones, that is when 
the number is large, are very frequently connected with arthritis deformans, 
a malady generally ascribed to the rheumatic taint. 

Since 1558, when Ambrose Pare first detected a movable body in the 
knee-joint, the mode of formation and growth of such substances lying 
free within a cavity has been the subject of much conjecture, and latterly 
of investigation ; nor have opinions on the matter greatly coincided, as is 
only natural, seeing that in reality their genesis is even more various than 
their structure. This may be : 

1. By hypertrophy and metamorphosis from one or more of the synovial 
fringes. 2. By histogenetic transformation of some spot or spots of the 
para-synovial tissue. 3. By growth from the periosteum at the edge of the 
articular cartilage. 4 By organization of a clot of fibrin or of blood effused 
within the joint. 5. By direct growth from the articular cartilage. 6. By 
detachment through injury of a piece of the normal joint. 

The first of these methods of growth has been more particularly studied 
by Mr. G. Rainey, whose account, although he was wrong in supposing 
that this was the only mode of formation, I cannot do better than tran- 
scribe. 

"These bodies have a distinct investing membrane, which on its exter- 
nal surface is smooth ; but by its internal one is so intimately connected 
to the body itself as to admit of being detached only by small shreds. 

" This membrane is composed of fibro-cellular tissue mixed with gran- 
ular matter. 

"Their internal structure, as exhibited by a section through their 
middle, is seen by the naked eye to consist of two distinct substances— the 
one being semi-transparent, like fibro-cartilage, the other perfectly opaque 
and white, like bone. The former, under the microscope, presents the 
appearances usually seen in fibro-cartilage ; the latter resembles remark- 
ably in its ultimate structure those bones which consist only of one bony 
plate placed between two folds of membrane, as the thin plate of the eth- 
moid. In the bones, the lacunae, as in the opaque parts of the bodies be- 
fore mentioned, are the same as in other bones ; but there are no distinct 
or well-formed canaliculi branching out of them. There is in both a stellate 
arrangement of the earthy matter around the lacunas, but nothing like 
canaliculi, and this appearance is more striking in the bones alluded to than 
in the earthy parts of these bodies. 

" I believe no satisfactory explanation has yet been given of the manner 
in which these bodies are formed in joints, although I think their origin, 
and the circumstances of their becoming loose in a joint, will appear ob- 
vious, by a reference to the remarkable character of the epithelium in 
joints ; the thecae of t fTlflP"" «""3. nmaoiiH bursas." 



182 DISEASES OF THE JOINTS. 

Mr. Rainey then gives the description of synovial villi and their secon- 
dary sacculi, already quoted (p. 12), and goes on to say : 

" Now, this being the apparatus by which synovia is elaborated in all 
parts, in which this fluid is found, and the bodies thus described being 
found in these situations, they may be inferred to be the product of disease 
in these structures ; the cellules of these fringes, in the place of elaborating- 
synovia from the blood, producing, under the influence of morbid action, 
other products, such as cartilage, which becomes converted into imperfectly 
formed bone. The fact of the secondary sacculi being connected to the 
primary by extremely narrow pediculi will suffice to explain the reason 
why these bodies may become formed in the first instance ; the pedicle 
serving both to keep them attached, and to convey the material from the 
blood necessary for their development until they acquire a certain size ; 
but afterward, from its tenuity being no longer capable of holding them, 
it breaks, and the bodies become loose and most likely cease to enlarge." ' 

The lipomatous bodies which I removed from the knee of Alice D. were 
formed simply by hypertrophy of an adipose tuft (see p. 193). Neverthe- 
less, it will be evident that such growths might also arise in the second 
method, but without inflammatory antecedents. 

The second method of growth is by direct metamorphosis of tissue. 
There are not a few conditions, traumatic and constitutional, which give 
rise to such changes in the immediate neighborhood of joints and else- 
where. Under the influence of a direct hyperplasia resulting from a blow, 
a punctured wound, or a certain dyscrasia, a nodule of fibrin is deposited 
in the fine tissue immediately underlying the basement-membrane. In 
this nodule a few cartilage-cells will be deposited, which, gradually gather- 
ing hyaline substance, and developing fresh cells, enlarge the original sub- 
stance till it becomes a cartilaginous, perhaps an ossifying plate or menisc, 
which, pressing inward, causes the synovial membrane to bulge into the 
joint-space. Increasing in thickness, and exposed therefore to more and 
more outward pressure, it protrudes farther and farther until it quite in- 
trudes, hanging by a broad fold — a sort of mesentery — upon the side 'of 
the cavity. It now comes within the influence of the joint movements, 
which, rolling it from place to place, pull upon and elongate this fold into 
a pedicle, which as it grows in length diminishes in thickness, until it at 
last gives way altogether. The plate which originated without has now 
become a free body within the joint. 

The third mode of development is in its mechanism, similar, but the 
place of origin is different, namely, from the parts just outside the synovial 
basement where that tissue joins the periosteum. In certain conditions 
connected with the rheumatic diathesis with arthritis deformans, or with 
the form of injury which conduces to the malumcoxce senile, there is a very 
strongly marked tendency to the production of osteophytes around and in 
the neighborhood of this place of transition. Those which lie nearest to the 
synovial membrane are very liable to be protruded into it as above described, 
when the mechanism of its further intrusion and liberation is identical. 

We are indebted to John Hunter for our knowledge of the fourth species 
of loose body ; they are, however, not very common. The formation of 
such substance from a fibrinous concretum or blood-clot within the joint 
can only arise after injury or after a rather acute synovitis, which, as already 
stated, may produce such deposit (p. 26). Probably only those clots which 

1 Pathological Transactions, vol. ii., 1348, pp. 110. l'l, Mr. Rainey's examination 
of some false bodies from the elbow-joint exhibited by Mr. Solly. 



ON MOVABLE BODIES IN JOINTS. 183 

are adherent can undergo the subsequent changes into cartilage or bone. 
The several false bodies which occasionally form after the extraction of a 
single one, in all probability owe their origin to an effusion of blood from, 
the operation wound into the cavity, but they may also be produced by 
fringe-growth from the united but irritable synovial wound. 

Direct growth of a tumor from the surface of an articular cartilage is a 
very rare event (ecchondrosis), its etiology entirely unknown: A certain 
number of cases are on record, in which, after death or amputation, loose 
bodies, the subject of operation, have been found to fit accurately into gaps 
left by their detachment in the normal articular cartilage, 1 while a loose 
body, apparently broken off from a meniscus of the knee, is also recorded 
(Broadhurst: "St. George's Hospital Beports," vol. ii.). 

A few words about the correlations of these methods may here be said. 
The first mode of growth is more especially connected with that form of 
hydarthrosis in which a tuft-like growth renders the inner synovial surface 
dendritic, i.e., covered with branching growths that project into the cavity ; 
nevertheless single loose bodies doubtless originate from a hypertrophied 
fringe, the rest of the membrane being healthy, or nearly so ; in no such 
case does any persistent effusion distend the capsule until the accidents to 
which these growths give rise have occurred two or three times. When 
such bodies arise, as a consequence of dendritic growth general to the syno L 
vial surface, be it connected with hydarthrosis or with arthritis deformans, 
they are multiple, like those in the Kentucky negro's knee, or in the sailor's 
elbow already mentioned. 

We have seen (see Chapter "Vill. ) that several forms of hydarthrosis exist, 
that two of these are closely connected with the production of false bodies 
on the one hand, and with arthritis deformans on the other. It is very diffi- 
cult—perhaps often impossible — to distinguish clearly those cases of mul- 
tiple dendritic false bodies which are of chronic arthritic, and those which 
only are of synovitic origin. I do not think it correct to assume that this 
latter ever leads to or terminates in the former. When such mutation of 
disease appears to take place, the true explanation seems to be, that the case 
in question was from the first arthritis deformans ; that the synovial condi- 
tion being strongly marked made the deeper impression on the .surgeon's 
mind, and concealed from him the more significant, deeper-lying but less 
patent affection. I certainly have seen and operated on cases of hydarthro- 
sis with multiple false bodies, which have not led to the bony conditions of 
arthritis deformans — the operations resulting in cure or improvement. In 
examining a case of large joint-effusion with a number of false bodies, the 
surgeon must never lose sight of the fact that, underlying and producing 
this condition, there may possibly be a more important, and, as far as the 
joint-functions are concerned, a more serious malady. Much acumen and 
considerable acquaintance with articular disease will be required to guide 
him aright in his prognosis and choice of treatment. 

The second mode of growth is connected with arthritis deformans, the 
third has often a similar relationship, but with a less pronounced form of 
the malady ; and it may also be purely local, the result of an injury such 
as a nip or a blow, or even a slight wound in the immediate neighborhood 
of the synovial membrane. A very instructive case was shown by Mr. Shaw, 2 
of a loose body, in the centre of which a piece of a needle was found. The 



1 Klein: Virchow's Archiv, B. xxix. H. 1 and 2 ; Teale : Med. Chir. Trans. , vol. xxxix.; 
Paget : St. Bartholomew's Hospital Reports, vol. vi. 
i Patbol..,ffl— mm will wim i»i iiflgi ■■ ■■ 



184 DISEASES OP THE JOINTS. 

needle at the time of its inception only passed partly through the synovial 
membrane, or'did not pierce it at all, but remained in the subsynovial peri- 
articular tissue ; around the foreign body, with or without the previous for- 
mation of a blood-clot, hypersemia and hyperplasia would occur, cartilage 
become formed, the protrusions into the joints would take place in the man- 
ner above described (p. 182). ' 

The element of traumatism, so frequent in the history of single loose 
bodies, has induced certain surgeons, forgetful how easily hyperplasia may 
result from such causes, to argue that most, if not all, false bodies in joints 
are but chips from a natural joint-surface. The opinion of one with so 
large an experience as Mr. Square of Plymouth, deserves the highest con^ 
sideration ; but he confesses this, his view, to be merely conjectural, and 
that he has never made any microscopic examination. Judging from the 
portraits of the bodies excised, which he has given, 2 it would be impossible 
to identify them with any portion of a normal joint. Mr. Teale, whose 
views Sir J. Paget, unacquainted with them at the time of writing, has en- 
dorsed, tends to teach that portions of articular cartilage being killed by in- 
jury, are afterward discharged into the joint by a process of "quiet necrosis." 
Klein's case does not, as Sir J. Paget supposes, support this view, but be- 
longs to the class of direct and immediate chipping away of a piece of fresh 
unchanged normal cartilage. 

I would also call attention to the fact that in other cavities besides the 
articular, false bodies form, for instance in the peritoneal and in the tunica 
vaginalis testis. In this latter, cartilaginous plates of considerable size have 
been found. In neither of these situations could there be any question of 
chipping from a normal part. Neither is the mode of protrusion and intru- 
sion of a growth from without a cavity into its area confined to joints : tu- 
mors developed in the substance of the uterus will sometimes protrude into 
the cavity, form a stalk by elongation of the mucous membrane, become a 
pendulous, and occasionally an entirely loose polypus. 

Symptoms. — Sometimes, he who has a movable body in so important a 
joint as the knee will be led to discover its presence by no sense of pain, 
barely of inconvenience, but either by accident or perhaps by some " queer 
feeling," which will cause him to examine the part with the hand. He then 
feels a lump, which probably will glide from his touch like a mouse — Gelenk- 
maus, as the Germans call it. The first sign, however, of so unwelcome a 
companion, is frequently a sudden severe pain of an indescribable character ; 
the bones seem about to start from their places ; the "joint is loosened ; " 
but the limb is rigid, and the muscles fixed in spasm. The patient may fall 
violently, even though in a dangerous position, or, at the least, he will seek 
support on the nearest object until he can sit. The pain is described as 
sickening ; it is frequently accompanied by vomiting, and under its influ- 
ence strong men have fainted. There is at first great dread of any move, 
ment, though after a time comes the sense that, if the knee could only be 
straightened out or bent, all would be well. After a while, perhaps, a reso- 
lute effort, one way or the other, will release the joint ; in other cases, it can 
only remain in the position in which it was seized. The patient is put to 

1 It is only just to Mr. Shaw to state that the mode of formation above described 
differs from his own. He supposes the needle to have been entirely forced into the 
articular cartilage, and to have produced an ecchondrosis ; but this leaves otit of the 
account the pedicle which he describes as a prolongation of the synovial membrane 
quite surrounding the body. This I hold could have only been produced in the manner 
I have stated. 

,J London Medical Review, vol. ii. 



ON MOVABLE BODIES IN JOINTS. 185 

bed, and, in an uncertain number of hours, sometimes as many as seventy 
or eighty, the fixity relaxes. 

This sort of attack is produced by intrusion of the false body between 
the bones (femur and tibia). In its more severe forms, it may be taken as 
certainly indicative of a loose body, though it should be noted that a milder 
form of attack is sometimes caused by subluxation of a meniscus, usually 
the internal. Such events are followed, at all events at their first occur- 
rence, by pretty severe synovitis, while their frequent recurrence produces 
a great degree of dread and timidity of locomotion, and a more or less con- 
stant dwelling of the mind upon the matter. The joint, too, becomes stiffer 
and the limb weaker. Especially do patients dread its occurrence during 
sleep or half-sleep ; for with some persons turning in bed, or some half- 
unconscious movement of the limb, will even more easily than walking, en- 
tangle the body, and rouse the patient with a fit of severe suffering. These 
conditions will at last cause the sufferer to be most desirous of getting rid, 
even at some risk, of so troublesome a visitant. 

The surgeon who is called to a case in which these symptoms have oc- 
curred for the first time may have considerable difficulty in finding any 
loose body, because, even though relieved from between the bones, it may 
have glided into some synovial fold or other nook ; also because there will 
very likely be such an amount of effusion as will help to conceal it. In- 
deed, if the joint be pretty full of fluid, he had better not even seek until 
it has become emptied. He may, indeed, have to visit his patient two or 
three times before he can find the offending cause. But, if the attacks have 
been pretty frequent, and the patient be aware that such a body is in the 
knee, he will have made it an object of some study-; will have learnt its 
manners and habits ; he will know where it usually resides, where it can 
best be felt, and by what movements he can bring it there ; also, when it 
slips from this spot, he will have learnt its lurking places, or how to entice 
it out of them ; so that, unless a very unobservant person, he can be of 
great aid to his attendant. The surgeon should at first hunt for the 
" mouse " with the lightest possible touch, lest he scare it away, and his 
hand must be acutely alive to any abnormal projection ; when such is found, 
it must not be directly pressed on, but surrounded at a little distance by 
as many fingers as may be wanted, which gradually approach each other 
till the body is closely imprisoned among thtem. A disengaged finger of 
each hand may then make the body course from one to the other, investigate 
its mobility, size, hardness, etc. When the surgeon has himself learnt 
something of its customs, he may go to work with less timidity. It may 
aid him to know that the more common places for finding these growths is 
on either femoral condyle ; chiefly, in my experience, the outer, just above 
the junction of the bones ; but I have come across them in front of the 
femur in some cases, just over the patella ; in others, considerably higher. 
I have also found them on the tibia, a little way inside the ligamentum 
•patellae. 

When one of these substances has been found, the surgeon must look 
for others ; he will direct his patient to hold the one already caught, in 
place (sometimes a difficult matter with a body so fugitive, as aptly to 
suggest the term joint-mouse) ; and then, putting the limb into different 
postures, will search diligently and carefully for others ; but if the patient 
happen, by misadventure, to let his particular mouse escape, it must be cap- 
tured again, and the search recommenced. 

The growth or growths must then be examined in reference to their na- 
ture and fn nditinna. A mc » mr.paV.1c irr£2ularity about a joint must not 



186 DISEASES OF THE JOINTS. 

at once be considered a false body within the cavity ; if it be of an oval 
shape, and only glide a little way from side to side, and if it cannot be 
turned so that its long axis can be brought to be at a right angle to its 
former direction, the substance is probably not within the joint. Especially 
is scepticism valuable if the movable lump be a little above the outer con- 
dyle ; for there is at this situation a fold or reduplication of the vastus ex- 
ternus and its fascia, which in fat knees and when the synovial membrane 
is rather distended, and sometimes when neither of these circumstances ex- 
ist, slips inward and outward when pressed against the bone. . The shape 
of this movable piece, the line of its mobility, and some other circumstances 
evident in the sequel, make the diagnosis sufficiently clear. None of these 
bodies are so attached as to enjoy only a backward and forward movement ; 
they can all be made to travel in a circle, or at least a semicircle. Again, 
they are very seldom — at least those that give any trouble are very sel- 
dom — so closely attached but that they cannot be made to conceal themselves 
under some normal part, as the patella or its tendon, the tendon of the rec- 
tus, or one of the lateral ligaments. The intra-articular position of a mova- 
ble something always found at the same place, and incapable of being thus 
concealed, is questionable. 

If it have been clearly made out that the body is in the joint, its excur- 
siveness will show if it be quite loose or be still attached ; one in the latter 
condition will only travel a certain distance in a circle of certain radius 
around a particular spot ; a body which is quite loose can, when the patient 
or a surgeon has learnt its idiosyncrasies, be moved and manipYdated all 
over the cavity. 

I do not think it possible to make out its formation, i.e., whether osseous, 
cartilaginous, or a mixture of both ; but the lipomatous loose body is soft, 
and as it glides away from the pressure of the finger imparts a peculiar 
half-doughy, half-resilient feel that reminds one of an oyster or slug held 
between finger and thumb. 

The shape of such bodies is very easily made out, but, being covered by 
a considerable layer of soft tissue, they always impress one as being bigger 
than they really are. 

Treatment. — Before deciding upon any line of treatment it is necessary 
to consider the number of bodies within the joint. Few surgeons — and I 
am of the number — would be 'bold enough, or in most cases I may say un- 
wise enough, to extract a large number of such growths — chiefly for the 
reason that in such cases as may be gathered from the preceding section, 
the malady is a symptom merely of a grave disease, upon which the excision 
of such bodies could have no beneficial, but might be followed by injurious 
results. 

The treatment of a loose body was originally excision by direct opening 
of the joint ; it was an extremely dangerous proceeding, causing B. Bell to 
say that he would rather amputate the thigh in the upper third than under- 
take it ; and we must remember that such operation was in those days 
pretty generally fatal. In consequence of the dangers of this proceeding, 
many methods of fixing the bodies, in some harmless part of the joint, have 
been devised, the most usual of which are retentive bandages of various 
shapes, adhesive, non-adhesive, elastic and non-elastic, combined or not 
with blisters to the surface, keeping the substance fixed to a spot by pass- 
ing a needle through it from without ; passing a wire suture through in 
the same way ; also the serre-fine similarly employed, that is, kept in situ 
for a few days, until it is thought that adhesive inflammation has glued the 
body to the inner surface of the synovial membrane, or, what occurs quite 



ON MOVABLE BODIES IN JOINTS. 187 

as frequently, until violent inflammation necessitates their removal. All 
these plans are usually delusive ; the bandages, well applied, diminish the 
danger of the body getting between the bones ; but, sooner or later, gener- 
ally sooner, the accident recurs, to the great disappointment of the patient. 
Yet in the case of multiple bodies, one of which is troublesome, this treat- 
ment may be judiciously employed. The various little operations also may 
seem for a time successful ; but the body readily gets loose again. What 
else could we expect ? Knowing that the movements to which it is subject 
have power enough to stretch and break its original pedicle, we surely 
ought to expect that the same forces would have greater power over new 
and comparatively weak adhesions, even if such be really formed. The only 
means whereby efficacious relief can be given is removal of the body by 
operation from the joint-cavity, and of these operations there are two :: 
one by direct incision, 1 the other by subcutaneous opening of the capsule. 

It is, I imagine, unnecessary here to describe at length the little con- 
test between Mr. Syme and some who denied his claim ; it really does ap- 
pear that both he and M. Goyrand hit simultaneously on the method of 
trying to avoid the dangers which attended direct excision of the cartilage, 
by performing the operation subcutaneously and in two steps or stages : 1. 
Dividing the capsule with a tenotome through a puncture of the skin. 2. Af- 
ter some days, when the wound of the synovial membrane may safely be con- 
sidered healed, cutting through the skin and extracting the body from its 
new place. The surgeon, however, who has perfected this method and made it 
really feasible, which before his efforts it certainly was not, is Mr. Square, 
of Plymouth. He operates with a large-bladed tenotomy knife, and, before! 
opening the capsule of the joint, he digs and cuts a passage and a burial- 
place in the peri-articular tissue for the body to pass along and lie in ; then 
he opens the synovial membrane rather freely, so that small size of opening, 
as compared with bulk of substance, may offer no hindrance to its passage ; 
and then the body is squeezed and coaxed out of the joint-cavity into the 
prepared hollow. 

In spite of these and other efforts, the operation still remains a doubtful 
one : one that no surgeon, however skilful, can undertake feeling such cer- 
tainty of completing it as when operating for stone, strangulated hernia, 
tying a vessel, etc. In certain special cases, all the circumstances being 
most favorable, success may pretty confidently be predicated ; yet even in 
such failure not unfrequently results. In other cases less advantageously 
circumstanced, failure becomes more likely than success. Failure means, 
simply that, after opening the synovial membrane, the surgeon finds it im- 
possible to make the body pass out of the cavity. This may either result 
from the pedicle remaining entire, or from the body slipping away and be- 
coming lost or incapable of being brought back, or, having been thus several 
times recovered, gliding away again so often, that at last both patient and 
surgeon with great disgust acknowledge defeat. 

The direct method, as that by valvular or oblique opening is now called, 
is thus carried out ; the body is carefully fixed, and an assistant shifts the 
skin over the deeper parts. either upward or to one side, as may be most 
convenient. The surgeon then cuts straight down on the body, which either 
springs out at once or may be removed with any convenient instrument. 
This method is scarcely liable to failure, unless a somewhat clumsy assistant 

1 By this term I do not mean cutting straight into the joint. Every surgeon at th& 
present day would make the incision oblique or valvular — the term is used in con- 



188 



DISEASES OP THE JOINTS 



let the body escape his grasp, or unless the surgeon with insufficient cour- 
age make too small an opening. 

The dangers which attend this operation are such as surround wounds 
into joints, viz., suppurative inflammation with all its injurious, nay, often 
fatal consequences ; indeed, in certain hands, this has proved a highly dan- 
gerous, or rather deadly proceeding. Other surgeons, notably the late 
Carl Pock, 1 had very great success and immunity from ill consequences. I 
believe (but with our present surgical appliances the matter is of less mo- 
ment) that success is most likely to be attained by making an opening suf- 
iiciently wide to avoid much kneading or squeezing of the joint, and by 
carefully closing, as the body passes out, the passage behind it so as to 
prevent any entrance of air into the joint-cavity. This closing must be 
done by the assistant as rapidly as possible behind the extruding body, nor 
must he relax the pressure of his hands until the wound is dressed and oc- 
«luded. I now give statistics of the two different forms of operation and 
iheir results ; for even now it is necessary to form a judgment as to the 
relative value of these procedures, and therefore to have a wide overlook on 
results which have been hitherto attained. Up to a certain point great 
facilities are offered me, for I am in a position to quote two sets of tables ; 
the first that of M. Hippolyte Larrey, the second that of Dr. Benndorff." 

H. LARREY, 1860. 





Diebct Excision. 


Subcutaneous. 




Number. 


Per cent. 


Number. 


Per cent. 




98 

28 

5 


74.8 

21.3 

3.8 


19 

5 

15 


48.7 




12.8 




38.4 








131 


99.9 


39 


99.9 



BENNDORFF, 1867. 





Direct Excision. 


Subcutaneous. 




Number. 


Per cent. 


Number. 


Per cent. 




143 

32 

41 

2 


65.6 

14.6 

18.8 

0.9 


29 
5 
5 

12 


56.8 


Deaths 


9.8 
9.9 




. 23.5 








218 


99.9 


51 


100. 



1 Langenbeck's Archiv. 

2 Larrey gives his table in a discussion of the Parisian Society de Chirurgie. I quote 
from the Gazette des hopitaux, 1861, p. 267. Benndorff's statistics are in a These inau- 
gurate, published at Leipzig in 1869. I have, in spite of many endeavors, been 
unable to obtain this work. I quote from Virchow's Jahresbericht. There is still an- 



ON MOVABLE BODIES IN JOINTS. 



189 



In looking at these tables, one cannot but be struck with the smaller per- 
centage of failures for the subcutaneous method in Benndorff s statistics, 
and more especially by the fact that, while in 1861 Larrey found fifteen 
failures among thirty-nine cases, Benndorff found only twelve in 1867 among 
fifty- one cases. Larrey gives in every case the name of the operator, and I 
have been able for the larger number to verify his data, and thus I cannot 
but regard his table as the more reliable, since the divergence appears to 
arise, not from collection by Benndorff of a larger number of successes, but 
by omission of failures. 

If we consider the results of the subcutaneous method, we cannot but 
be struck with the small percentage of success : in the one table less than 
half the cases operated on ; in the other, nearly two-thirds only are cured ; 
while about one-eighth in the former, one-tenth in the latter die. The 
enormous proportion of failures indicates the unreliable nature of the oper- 
ation, and shows how difficult it is to estimate whether the body is in all 
respects so circumstanced as to render this mode of excision feasible. To 
this subject I must briefly revert. 

In the method by direct excision, a different set of facts comes to our 
notice. Here we have of success 75 per cent, in the one table, 80 per cent, 
in the other ; but we have also a rather high mortality and a considerable 
quantity of such grave complications as have endangered life, and either 
caused considerable or entire immobility of the joint. 

I have taken considerable pains to collect all the cases since 1859 I could 
find recorded in hospital reports, journals, Transactions, etc., that are accessi- 
ble to me. The cases are from almost every civilized country, and, with 
Larrey's table, will, I think, include nearly every published case since 1858. 

BARWELL— EIGHTY-EIGHT CASES— 1860-75. 





Direct. ' 


Subcutaneous. 




Number. 


Per cent. 


Number. 


Per cent. 


Success 


44 
4 


91.6 

8.4 


29 

1 

10 


72.5 


Deaths 


2 5 


Failures 


25.0 








48 


100.0 


40 


100.0 



This table gives in its small figures a very different ratio of success for 
both forms of excision ; but I cannot say that I regard the outcome as very 
indicative of the results of operation. It is not in man to publish his fail- 
ures, even though unsuccess be not due to his own fault. And it is a little 
remarkable that I find recorded no single case of failure, unless it have been 
redeemed by a subsequent operation. This consideration will, of course, 
affect the subcutaneous rather than the direct method ; a mere section of 



other table which is mentioned in the Societe de Chirurgie by M. de Chassaignac : it 
is ascribed by him to M. Bertheneon of Odessa ; but as it is somewhat singular in its 
results, I consider it hardly so reliable as to deserve quotation, and I find no mention 
of such writer in any publisher's list. 

' Among the cases of direct excisions five were performed antiseptically. 



190 DISEASES OP THE JOINTS. 

the joint under the skin without result will be more likely to escape notice 
than an operation followed by death or other grave results. 

Moreover, it is evident that modern surgery has introduced greater at- 
tention to cleanliness, greater care in exclusion of air, and other means, 
which render opening a synovial membrane a far less dangerous proceeding 
than formerly ; while it may well be doubted whether, since Mr. Square 
began his improvements, anything remains to be done for the perfection of 
the subcutaneous mode ; but that surgeon had four failures in fourteen 
operations. 

I have excised a large number of loose cartilages, and have never ex- 
perienced either a failure or an untoward event. One patient operated on 
before I had come to place faith in antisepticism, experienced some time 
after the wound was closed a smart attack of synovitis — either not at all or 
only indirectly connected with the operation. Those operated on antisepti- 
cally had no synovitis, nor indeed any adverse symptom. 

In such operation, antiseptic precautions must be rigidly enforced. The 
opening should be free enough to allow the body to jump out at once. If 
it do not do so, its position must be carefully ascertained from without, and 
either the finger or a vulsellum passed into the wound, the body seized and 
carefully extracted, the greatest care being taken not to take up, pinch, or 
in any way roughly use the synovial membrane. All these directions are 
easily followed, but not so the rule to cut down on the body. To make an 
incision of considerable depth down upon a body so movable as a joint- 
mouse, without driving it out of position, is impossible. I have therefore, 
in my later operations, selected a place where the body either habitually 
lies or passes to, from the immediate vicinity with great ease ; I take care 
that the substance lies close to it, and cut into the joint there, where, viz., the 
body is not ; and then from its situation close by, where it has lain undis- 
turbed, the slightest pressure will cause it to extrude, if it be not bound 
down by a pedicle, the treatment of which will be evident from the cases 
recorded. 

Case LI. — J. M., a sailor, aged forty-two, sustained a fracture of the 
humerus through the condyles in February, 1858. The bone united well, 
and in four months he went to sea again with good and but very slightly 
restricted movement of the elbow-joint. He returned to. me at Charing 
Cross Hospital to show me the limb. The elbow-joint was rather weak, 
and contained a large quantity of fluid, together with a number of loose 
bodies. I counted eleven such in the joint itself. There was besides a pouch- 
like elongation of the synovial membrane upward above the inner condyle : 
this was the size of a bantam's egg, contained a considerable amount of 
fluid, and a number which could not be counted, but which I should esti- 
mate at from 30 to 40, of easily movable bodies ; the sac felt like a bag of 
marbles. I tried to detain this man, but after the manner of sailors he 
disappeared. Except that his arm was a little weak, he felt no inconveni- 
ence from the condition of the elbow. 

The next case, referred to in the text as suffering a subsequent synovi- 
tis, is remarkable in its history, which appears scarcely compatible with the 
symptoms. The genesis of the little bony lump is quite obscure. 

Case LH. — C. H., aged forty-three, came into my room on July 21, 1875, 
and reminded me of his having consulted me in 1872 on account of pain 
and difficulty on moving his right knee. He further reminded me that I, 




ON MOVABLE BODIES IN JOINTS. 191 

finding him in a very rheumatic condition, had counselled a residence 
abroad, and that I had mentioned the proclivity of his then condition 
toward forming one or more false bodies in the affected knee. I remem- 
bered, as he mentioned it, having been impressed by the peculiar rough con- 
dition and the grating of his synovial membrane. 

He gave the following history of his condition at the above date. In 
the last week of May he tried to get into a carriage of the Metropolitan Rail- 
way whilst it was in motion. He struck his knee sharply, and was thrown 
back, with some violence, upon the platform : got up quickly, and out of 
the way, fearing to be taken in charge. The next day he found a loose 
boly in the knee ; he had no synovitis or pain. He also said that, after 
this accident, he missed a lump which he previously had over the inner 
condyle. 

I found the body easily at the time, and on several subsequent occa- 
sions ; it had no fixed residence but, by certain movements of the limb, the 
patient could bring it into view. It appeared somewhat 
rough, hard, and about the size of a horse-bean. It could 
be moved into almost any part of the knee, but most easily 
into the subcrureal sac. As a merely temporary expedient, 
I fastened it in that situation with pad and strapping. It 
remained stationary after this for a day or two, then slipped 
away, and caused a good deal of pain. Though he had never 
had a violent seizure, the annoyance was so considerable, 
and being a nervous person, the dread of such an attack was b6a Fl< x, 9 f -— f oose 
so troublesome, that he greatly dfcsired removal of the body. 

July 10th. — I got the body into place where it could be best fixed — viz., 
above the outer condyle — and operated after Square's method, but the body 
would not pass out ; it slipped away, and could not be found. 

July 17th. — No bad symptoms had resulted, and, prior to opening the 
membrane, I made an attempt to fix the body with a Glover's needle in a 
properly constructed needle-holder. I found it so hard, that it was impos- 
sible to introduce the point. I declined to attempt subcutaneous removal, 
fearing another failure under these conditions. 

July 31st. — He was determined to have the body removed ; and I ope- 
rated at the place where the body could best be fixed, viz., above the outer 
condyle, with considerable shifting of the skin, and perfect exclusion of air, 
with instruments well cleaned with carbolic acid. The body would not 
come of itself from the joint, and I had some difficulty, owing to its round- 
ness and hardness, in getting any forceps to hold it ; but, after a little, I 
succeeded in extracting it, the edges of the wound being held close behind 
the body, so as to obviate any entrance of air. It was stitched, painted 
with collodion, and, when this was dry, covered with cotton-wool ; the limb 
was then placed on an Amesbury splint. Barely any swelling took place ; 
the part remained free from pain, though slight tenderness round the wound 
could, as might be expected, be discovered. In fact, I regarded the patient 
as convalescent, when, on the morning of August 8th, I was sent for in 
great haste. I found that he had, feeling some slight pain the day before, 
discarded the warm applications that I, knowing his rheumatic tendency, 
had prescribed, and used a spray of cold — I believe ice-cold — water. A com- 
plication arose, which had nothing to do with the operation. The knee 
swelled ; the swelling did not fluctuate ; it was rather hard, and not rounded 
like acute synovitis. The pain seemed to be severe ; but the temperature 
never reached 100°, nor were there other signs of pyrexia. The attack was, 
I believe, rheumatic, a condition to which he was very subject, combined 



192 DISEASES OF THE JOINTS. 

with neuralgia. Convalescence was rather tardy. In the middle of Sep- 
tember he went down-stairs, and shortly afterward was out of doors. In 
the middle of October he went to Scotland, where he soon recovered the 
full use of the limb. " ' 

The body seemed nearly as hard as the enamel of teeth ; it had adher- 
ing to it some shreds of membrane, which probably were the remains of 
the pedicle. No broken bony or calcareous part indicated that a hard stalk 
had been snapped off by the accident above described. This body is now 
in the Museum of the College of Surgeons. Pathol. Series, No. 957C. 

Again, in my second case, we have history of injury ; and again the body 
shows every appearance of being no normal part of the joint, but a growth 
in the immediate subsynovial tissue ; the first impulse to which was doubt- 
less given by a blow, setting up first inflammatory, and then formative, 
action, as described in my first Lecture. The body was, I am sorry to say, 
lost in the theatre, while I was performing another operation, by some in- 
advertence of one to whom it was entrusted. I had carefully examined it ; 
it was an oval plano-concave plate of cartilage : the concave side was toward 
the joint cavity, the plain side directed toward the superficies. In dimen- 
sions, its long axis was nearly an inch, its short axis rather over half an 
inch ; the thickest part, namely the edge, was as thick as a not very new 
shilling. One of the long sides of the oval had on it a shallow gap or bay, 
so that the whole outline was somewhat kidney- or ear-shaped. The carti- 
lage composing this substance had the bluish tinge of the hyaline variety 
of structure ; about the centre, its thinnest portion, two or three roughened 
and whitened spots showed that plates of calciform matter had been de- 
posited. All one surface, and a portion ,of the other, had attached to it a 
fine vascular membrane ; I have no doubt this was a protruded mesentery 
or stalk, if I may so call it, formed from synovial tissue ; neither have I any 
doubt that this body was one of those formed in the tissue immediately 
underlying that structure. 

Case LIU — T. de G., aged twenty-six, tailor, was admitted under my 
care into the Charing Cross Hospital on October 15, 1875, saying that he 
had a loose body in his knee (left). "When thirteen years of age, a large 
stone fell on his knee ; he suffered no pain or trouble at the time. He first 
discovered some loose substance in the knee six years ago ; it was then, he 
said, situated over the inner condyle of the femur, and was but slightly 
movable. For two years it remained in this place, and he thought noth- 
ing of it. In 1871, after a long walk, it suddenly slipped between the 
bones ; he fell down with the pain, and was very sick and faint. After- 
ward the knee swelled, and he had to lay up. The same thing recurred 
several times, though not for some months, yet he so dreaded the accident, 
that he was determined to have the substance removed. The body's fav- 
orite resting-place was at the outer condyle, but it had considerable range, 
though apparently not quite free movement ; it felt flat, about the size of a 
sixpence.' 

November 3d. — Under chloroform and carbolic acid spray, and with the 
skin a good deal pulled inward, I made a semilunar incision over the body, 
and deepened it till I felt the synovial membrane loose below my finger. I 
waited a few seconds to see that the bleeding was quite trifling, and then 



1 I believe his story as to the place where the body first appeared to be extremely 
doubtful. 




OK MOVABLE BODIES IN JOINTS. 193 

opened the joint. The body did not come to the surface, as is usual with 
free ones, nor did I see it at the bottom of the wound. I passed my fiugei- 
very gently in, and felt that it had slipped a little, so that its inner edge 
only lay under the outer lip of the wound. I introduced a very narrow- 
bladed forceps, and lifted the body into the wound. It was attached by a 
rather broad pedicle, and this had to be divided before the substance could 
be removed. The lips of the wound were stitched with 
carbolized gut, dried rapidly, and thickly covered with 
collodion ; the limb placed on a Maclntyre splint, with 
a thick pad of cotton-wool over the joint, and the whole 
put on a swing-cradle. No synovia flowed during the 
operation, and I believe no air entered the wound. 

During the first week he had occasional attacks of Natural sizeT °° 8e ° y ' 
pain in the knee ; these were paroxysmal, and of the 
sort which occur in the malady which I have termed dry or fibrinous syno- 
vitis. A blister was applied above the joint, across the front of the thigh ; 
this relieved the pain ; the temperature was never more than 99.2°. 

November 17th. — He was allowed to get up. The limb was a little stiff 
from confinement. 

November 23d. — He went out walking well, with barely any stiffness. 
In ten days this stiffness had quite worn off. 

The next case is one of interest in many ways. Firstly, lipomatous 
growths are by no means uncommon, either in the peritoneum or in the 
tunica vaginalis ; and at these places they appear as pedunculated or as 
loose bodies ; but so large a fatty growth, arising from a synovial mem- 
brane, is very rare. Secondly, the surgical value of the case is very con- 
siderable. Hydarthrosis frequently is incurable, either by iodine injections 
or other means ; and the knee of A. D. would probably have belonged to 
this class of irremediable disease if the bodies had not been excised. 
Whether most cases of very obstinate hydarthrosis —those that resist every 
treatment — are dependent on the presence of undiscovered, perhaps undis- 
coverable growths or membranous adhesions, is a subject for future con- 
sideration ; as yet, data are not forthcoming for the solution of this ques- 
tion. A. D. has suffered no pain, no weakness, no swelling of the left knee, 
since she recovered from the operation ; but a strongly marked condition, 
constitutional or local, is present, which so disposes those joints to hydar- 
throsis that the other knee appears to be taking on similar action. 

Case LIV. — Alice D., aged twenty-six, was admitted under my care into 
Charing Cross Hospital, on October 16th, with hydarthrosis of left knee. 
She is a tall, stout, healthy young woman, but hysterical. In examining 
the joint, I found, just above the patella, a movable body, which seemed 
soft and rather large ; and, on further examination, detected over the outer 
condyle another such growth. These bodies enjoyed but a small range of 
motion. The knee was large, and contained a considerable quantity of 
fluid ; but it should be noted that both knees were fat and big ; the follow- 
ing are the dimensions : 

Eight. Left. 

Over patella 14£ inches. 17f inches. 

Across " 14 " 15f " 

Beneath " 13 " 14£ " 



194 DISEASES OE THE JOINTS. 

In consequence of great press of patients for admission, I was obliged 
bo send her out until another vacancy could be procured. The rest had 
been of some benefit ; on her leaving, the dimensions of the left knee were : 
over patella, 17£ inches ; across, 15£ inches ; beneath, 14£ inches. 

November 2d. — A. D. was readmitted. She had been suffering a good 
deal of pain in the knee, especially when walking, which she did with diffi- 
culty. The size was again increased : above patella, 17f inches ; across, 
15f inches ; beneath, 14£ inches. 

It will be observed that the chief swelling, as in all cases of hydar- 
throsis, is above the patella, and this is the site of the loose bodies. I 
«xamined the bodies very carefully ; they appeared oval, and about the size 
of ordinary spectacle-glasses, and about as thick through as their short 
diameter, the inner one being rather the larger ; they were rather soft, and 
■enjoyed no large range of motion ; the inner one, which lay in front of the 
femur, with its lower edge about half an inch above the patella, could be 
pushed to the inner condyle, but not to the outer ; it could be pressed 
under the patella, also, about an inch and a half higher than its usual seat. 
The outer one had a more limited range ; it could be made to describe a 
semicircle round the outer side of the outer condyle, its end protruding a 
little way under the patella. 

Previous to the discovery of these bodies, I had intended to treat the 
hydarthrosis by injection, but now this appeared to me futile while they 
Temained in the joint ; and, with the consent of my colleagues, I deter- 
mined to excise them. 

November 20th. — She had been kept in bed since her admission for 
twelve days, with her leg on a pillow ; the swelling of the knee had some- 
what decreased. A week ago, I had the limb placed on a Maclntyre 
splint, and fixed the above date for operation. Yesterday, the knee being 
measured, gave the following dimensions : above patella, 17 inches ; across, 
15£ inches ; below, 14 inches. 

I operated, the patient being under chloroform, with the antiseptic pre- 
cautions, by making a slightly curved longitudinal incision above and on 

the inner margin of the external con- 
dyle ; this I gradually deepened, and, 
waiting till the slight hemorrhage had 
nearly ceased, I opened the synovial 
membrane. After a little manoeuvr- 
ing, the outer body sprang out, and 
hung by a small stalk ; this was cut 
through. I found it impossible to get 
the inner body to protrude. I there- 
fore wiped all blood from my finger ; 
and, after subjecting it for a while to 
the spray, introduced it carefully into 
fig. aa.- Representations (natural sizej of the the joint, easily found the body, but 
bodies removed. The one on the right ia that could not draw it further inward. I 

which grew from the inner condyle ; the left, that » ,, ,., .,, „ n.. 

which grew from the outer. followed it with my finger across tee 

joint to the inner condyle, and tried 
to detach it, but was foiled. I now seized it in a pair of forceps, drew it 
as far as possible out of the wound, and, with a scalpel introduced as far 
as was safe, separated it, leaving a very small part of the body behind, in 
the hope that it would shrivel away. A good deal of synovia flowed during 
the operation. The bodies were lipomatous, and, while warm, looked, ex- 
cept that they were more pear-shaped, exactly like native oysters without 





ON MOVABLE BODIES IN JOINTS. 195 

the beard ; the color and size were exact imitations while they were warm, 
but, on getting cold, the translucent parts changed in appearance, and then 
became still more white and opaque on being put into spirit. 

December 2d. — She had had occasional attacks of pain, but not severe. 
The temperature varied from 98.4° to 100° ; pulse quite normal. I undid 
the bandages, removed the cotton-wool and the collodion covering, which 
was rather loose. The wound had not healed. Between its lips was a clot 
of blood, looking as purple and as fresh as though it had only just been 
effused. The knee appeared a good deal smaller than it was before opera- 
tion ; she had some slight tenderness over the whole joint, but chiefly at a 
place over the inner condyle, which she, unprompted, described as "the 
place where you removed the larger body." 

December 13th. — The wound was healed. There was hardly any ten-* 
derness, probably no real tenderness ; but it was difficult to judge. She 
had rather frequent and prolonged fits of hysterical weeping. I removed 
the splint, and moved the leg through about 30° quite smoothly and with- 
out pain. 

December 23d. — She went out walking, well and free from pain. The 
size of the knee was : above patella, 15 inches ; across, 14£ inches ; below, 
13| inches. 

March 8th. — The patient not having presented herself for examination 
as ordered, I found her at her residence. The knee was perfectly well, 
having the same dimensions as above. The part of the inner loose body 
which I bad been obliged to leave attached could not be detected. The 
other knee showed some swelling and tendency to hydarthrosis. She stated 
that she never had any pain nor sense of weakness in the left, the operated 
knee, but occasional pain in the other. 

In considering the result of these cases and the choice of operation, it 
is to be observed that the subcutaneous method must have failed in the two 
last, the bodies being, all three of them, attached to the synovial membrane 
of the joint. The fact of their having marked limits to their mobility- 
much wider in the case of de G. than in that of Alice D.— had apprised 
me of this condition. In the first case, although the body was evidently per- 
fectly free, and although I made a quite sufficiently wide opening in the 
capsule of the joint, it was impossible to extrude the substance : this I at- 
tribute to its hardness and to its rounded shape. These observations bear 
out the remarks that the subcutaneous method must in certain cases fail, 
and that such mode of operation should be avoided when limited mobility 
indicates persistence of the peduncle ; further, that such method will occa- 
sionally fail, even when larger mobility exists, and gives assurance of an 
entirely free substance. 

I have commenced this section on the treatment of loose bodies with a 
description of operative procedures, because they are the only means by 
which a cure can be assured ; but mention must also be made of certain 
other methods, which, though less reliable, are nevertheless valuable. These 
all resolve themselves into devices for retaining the body for a certain time 
in some definite spot of the joint-sac. I should unhesitatingly reject all the 
plans which necessitate transfixing a fold of the synovial membrane, 
whether with a hair-lip pin, a silver wire, or a serre-fine, they being less 
efficacious and quite as dangerous as excision properly performed. Thus 
the permissible methods can only consist of some well-devised means of 
exerting pressure from without, not upon but around the false body, pre- 
viously Tnn.Tii Twi'ln.t.nri into a. pnnv AnipTi>.-nr»gifir.n 



196 DISEASES OP THE JOINTS. 

Several folds of lint, into which a hole of commensurable size has been 
cut, may be so placed and fixed with strapping-plaster, that the body lies 
in the opening, while firm pressure all around it tends to prevent its escape. 
Lint, however, is, as a rule, too soft a substance for this purpose. Better 
materials are either the sort of sole-leather used for splints, or some soft 
metal, either lead or pewter, in sheet, about a quarter of an inch thick. If 
the former be preferred, it should be cut of proper size, a circle or oval, 
about 1\ inches in diameter ; in it a hole should be made, which is to re- 
ceive the slightly projecting body. The leather is then to be steeped in hot 
water, with a little vinegar, and to be firmly bandaged on the limb. The 
same mode of arrangement, except the steeping, is suitable for a pad made 
of soft metal, but a piece of thin mackintosh, especially if lead be used, is 
• to be introduced between the metal and the skin, lest deleterious absorp- 
tion take place. When the leather has become dry, strapping-plaster may 
be substituted for the bandage ; it may be used at once as the best means 
of securing a metal pad. 

These devices are valuable as palliative treatment, or as means of im- . 
pounding a body which perhaps has been found with difficulty, until the 
next visit, or until preparations for operation are completed. 1 

If there be in the joint a multitude of false bodies, some of which are 
troublesome, alleviation may be effected by kneading and manipulating 
them into some favorable position — as, for instance, for the knee, the sub- 
crureal pouch, or for the elbow, the dilatation near the inner condyle, caus- 
ing them to be carefully held in place by an assistant, emptying the joint 
by aspiration, passing a perforated metal pad over the whole collection, and 
tightly enveloping the limb in plaster-of-Paris. When the bandage is re- 
moved, several bodies are generally found pretty closely attached, and the 
movement of others is very much restricted. 

I described at p. 184. the sudden painful attack which often gives the 
first intimation that a false body is in the knee. It must, however, be said 
that a similar seizure may follow displacement of a meniscus. On the first 
occasion, if the patient seek advice while the joint is still painful and stiff, 
the surgeon may detect abnormal prominence of an inter-articular carti- 
lage, or may not be able to define which condition produces the symptoms ; 
nor is the immediate diagnosis important, since the first treatment in either 
contingency is alike, namely, to restore mobility. This is done (an anses- 
thetic may be necessary) by bending the patient's knee to the full extent. 
The joint should then again be examined. It may be that a false body will 
be found ; if not, the following hints may aid diagnosis. Subluxation of a 
menisc causes less pain than a joint-mouse ; the knee is fixed in a straighter 
posture ; there is distinct tenderness at the spot, often a prominence, which 
on flexion disappears. Subsequent synovitis is not so common, and when 
it occurs is less acute. The synovial membrane is smooth. After replace- 
ment, a bandage should be firmly applied, and, for a few weeks afterward, 
an elastic bandage or knee-cap should be worn. 

1 On one occasion I thus fixed a rather small but very troublesome falee body, and 
three days afterward found that it was hardly mobile. I repeated the application, 
and found the adhesions become firmer ; my patient was cured. A tolerably long ac- 
quaintance justifies the assertion. 



ON DISEASES COMMENCING IN THE BONES. 



CHAPTEK X. 

ACUTE ARTICULAR OSTITIS. 



The diseases of the joints hitherto examined have all taken their rise in 
the soft parts, that is, in the synovial membrane and subsynovial tissue. 
. Another class of these maladies begin in the bone ; like those already de- 
scribed, these all originate in inflammation ; ' and ostitis is a disease that 
has been known from time immemorial. In the next few chapters, as I wish 
to designate those osseous inflammations which, situated close to a joint, 
affect the integrity of its mechanism, I shall term the diseases articular 
ostitis of different kinds, meaning by that term inflammation of a joint- 
bone. 

Some writers would wish to confound together all articular affections, 
whether arising in one structure or another, under the name " joint disease," 
chiefly, as it appears to me, because it is barely possible at the end of a de- 
structive malady to decide on the place of its commencement. The two artic- 
ular constituents prone to disease are, however, as different in their physiol- 
ogy and pathology as are any two neighboring structures of the same body. 
Is he wrong who would divide pleurisy from pneumonia, and both from bron- 
chitis, who would separate meningitis from cerebritis, conjunctivitis from 
sclerotitis ? If not, why is the attempt to distinguish between two differ- 
ent forms of articular disease to be called " to separate natural wholes into 
artificiarparts, to dissect disease ? " 2 It appears to me, that the separation 
of different forms of disease, occurring in complex parts, is that point in 
modern surgery upon which our progress chiefly depends. I certainly 
should not have dreamed that the distinction between a bone and a syno- 
vial membrane could ever be considered "artificial." 

No one who has seen a case or two, for instance, of acute ostitis, but 
must be impressed with the fact that early recognition of the malady gives 
oyer it a power that is inevitably lost if the surgeon, considering it "joint 
disease " and nothing else, wait till the worst is fully developed. In chronic 
maladies, owning the same origin, the like fact, if less striking, is neverthe- 
less not less true. 

In certain cases even, if our accurate knowledge of the malady, of what 
it is doing, and to what it will lead, may not greatly add to our power of 
treatment, it will give us at least that of prognosis. We can tell our patient 

1 Malignant disease and tumors, either of soft parts or of bone, do not come under 
our consideration. 

'Surgical Treatment of Children's Diseases, T. Holmes, p. 411. 



198 DISEASES OF THE JOINTS. 

or his friends what state the disease will leave him in ; we can give him a. 
definite assurance of the future, which must be denied to the believer of 
" joint disease as a whole." • 

I, therefore, do not doubt that, as our knowledge of the processes of dis- 
eases in the joints advances and approaches nearer to the precision of our 
acquaintance with those in the eye, so will the distinctions between the one 
form of malady and the other be more minutely drawn, and more univer- 
sally used and acknowledged ; that remedies more especially adapted to the 
individuality of the disease may be forthcoming, so that some which are 
now treated as " joint disease " will in the future be managed in a more 
discriminating manner. Even now, a very few years after the work above 
quoted has endeavored to discourage all attempts at differential diagnosis, 
Mr. Smith's cases,' and Mr. Brown's case, 2 show that the surgical mind has. 
advanced beyond such teaching. 

In carefully weighing the methods whereby I may most readily and 
surely convey a clear comprehension of the different clinical and pathologi- 
cal facts, with which experience and study have made me familiar, it has 
seemed to me impossible to include the whole series under the two classi- 
cal headings of acute and chronic, since either one or the other of these 
would of necessity embrace a wider range of actions than can fairly be de- * 
scribed under such headings. We have, namely, a certain form of bone 
inflammation, which terminates very quickly in widespread gangrene, or, 
as it is here termed, necrosis. Another, in which abscess forms within the 
bone, or in the cartilage about to become bone, with more or less rapidity, 
being accompanied by slight, only partial, and not very rapid necrosis. A 
third, in which the osseous tissue becomes in part sclerosed, in part soft- 
ened and fatty ; pus forming slowly, if at all, its production not being a 
prominent portion of the morbid act, while necrosis is generally altogether 
absent, or may be molecular, or of a carious character. These considera- 
tions have led me to divide such ostitis, as we have to do with in a treatise 
on joint disease, into three sections, which may, I think, most judiciously 
be termed peracute, acute, and chronic. I prefer these " designations to 
acute, subacute, and chronic, because the middle term of the three, that 
which tends with considerable rapidity to abscess in a joinfc-end, is often of 
too rapid a nature to come fairly under the class subacute. 

Peracute Articular Ostitis. — If chronic affections of bone-tissue are the 
slowest of all maladies with which the surgeon has to do, so are acute dis- 
eases of those parts among the most rapid and most formidable, not merely 
on account of their local, but also of their general effect. Nevertheless,, 
even in those forms of inflammation which fully deserve the title of acute, 
there are sundry degrees of violence, and certain differences of form, which 
render some classes of the disease much more severe and more constantly 
fatal than others. It is to be understood, from the beginning, that the 
whole bone-tissue, with its membranes, both lining and investing, are in 
these cases involved, hence the term osteo-myelitis. In some the action is 
circumscribed (osteo-myelitis, circumscripta) ; in others, diffused (diffusa) ; 
and this form frequently partakes of the nature of phlegmon or erysipelas, 
with phlebitis of soft parts ; hence the term osteo-phlebitis diffusa. On 
the different degrees of gravity of maladies so named I need scarcely here 
insist. 

Peracute ostitis is almost confined to young life, and to the ends of 

■Bartholomew's Hospital Reports, vol. x., p. 190. 
2 Clinical Society Transactions, vol. ix. , p. 175. 



ACUTE ARTICULAR OSTITIS. 199 

long bones. At all events, this is the one form of disease which interests 
us here. It involves either, first, the epiphysis, and spreading, thence by- 
way of the periosteum to the next adjacent part of the shaft, or more fre- 
quently begins quite at the lower end of the shaft, and passes on to the 
epiphysis. In such position the inflammation is generally diffuse, though 
not of necessity phlebitic. Another form, less violent, commences on one 
or the other side of the epiphysal line, is generally circumscribed, or but 
partially diffuse ; it is less grave in character and symptoms, unless the re- 
sultant pus pass into the neighboring joint. 

I propose to commence with the former class of disease. It has been 
ascribed to some violence, even though slight, to severe chill, or over-exer- 
tion, and again by others has been considered as the local expression of a 
systemic cachexia. The same divergence of view concerning the origin of 
erysipelas and erysipeloid inflammations of soft parts, diffuse phlegmon and 
phlebitis exists. To my mind it appears impossible that any one part of 
the body can be affected by a violent non-mechanical disease, that shall be 
entirely local. It is important to bear in mind that occasionally the malady 
is multiple, that is to say, a number of bones are involved in such rapid 
succession, that they seem simultaneously attacked. No ordinary local 
injury could in a healthy state of system set up such perbulent action, for 
every healthy child running and romping about the world receives un- 
harmed a number of knocks and bruises far more severe than those to 
which this disease has often been ascribed. Yet it must be remembered 
that local pain, heat and tenderness do as a rule precede, if only by a short 
time, systemic manifestations. Hence there is good ground for believing 
that certain local disturbances ; which, under favorable conditions, would 
remain within moderate bounds, can surge into violent and destrucftve 
disease if they happen to coincide with a moment when the constitution is 
worn by over-fatigue, want of good or sufficient food, and fresh air, or is 
depressed by severe chill, perhaps even by malarious influence. 

Such conditions act with greater power upon the immature constitution 
of the young ; and it is at that period of life that the bones are in a state 
of great formative excitement, accompanied at their extremities by a hyper- 
emia and tension, that very easily oversteps the narrow limit which sepa- 
rates it on the one hand from inflammation, on the other from congestion 
and venous stasis. Moreover, we cannot but be struck by this peculiarity, 
that the bone-ends, most liable to this form of disease, are precisely those 
whose increase has the most marked influence on the growth of the body, 
and at those ends of them where that activity chiefly prevails. Thus the 
malady is most frequent — 1st, at the lower end of the femur ; 2d, at the 
upper end of the tibia ; 3d, upper end of ulna, lower end of humerus, and 
lower end of tibia equally ; 4th, upper end of femur ; 5th, upper end of hu- 
merus. 

The disease commences with increased hypersemia of a part which, in 
earlier life, is already hypersemic, accompanied by blood extravasations of 
smaller or greater extent, and by effusion of more or less deeply blood- 
stained serum into the medullary hollow or cancellous cavities as the case 
may be. 1 These phenomena are closely followed by free proliferation of 

1 The minute anatomy of ostitis has been deferred to another chapter, since the 
conditions of the peracute form, though similar, are too hurried to form good material 
for investigation ; moreover, they are stopped at a certain point by death of the 
affected part. The reader therefore is referred to Chapter XI. for a full elucidation 
of this subject. In the very acute disease, the processes of absorption of lime-salts, 
formation of Howship's lacunae are by the venous stasis and suppurative energy 



200 DISEASES OE THE JOINTS. 

the medullary membrane, producing here pus, there soft granulation-tissue, 
which latter in the severe and diffuse cases is quite unstable, and soon 
melts away into puriform fluid ; but in the circumscribed cases persists in 
places, and forms boundaries to the localized abscess or abscesses. It is 
precisely on the persistent or transient nature of these limiting granula- 
tions that the diffuse or circumscribed nature of the case depends. If they 
are persistent, and tend to the formation of new tissue, the malady will end 
in a localized abscess or abscesses, with, in all probability, some partial 
necrosis surrounded by sclerosis. If, on the contrary, proliferation " of the 
medullary membrane produce chiefly pus and transient granulations, soon 
dissolving into a puriform fluid, no limiting tissue can be formed — the 
suppuration is diffuse. After a short interval' the hitherto semi-solid 
medulla dissolves into oil-drops, which mingle freely with the inflamma- 
tory fluids. At this period it is not usual to find the interior of the bone 
filled with diffused pus, although, in the worst form of disease, that de- 
scribed by Chassaignac and Klose, such appearance may occur. The medul- 
lary canal, or the spongy end, presents, when the bone is split lengthwise, 
a mottled aspect, part being of a reddish purple (highly vascular granula- 
tion-tissue), part yellow or orange (pus and blood) ; in some cases' the 
former, in others the latter hue will predominate. ■ In others again, pus 
collections connected by narrow channels, a chaplet of little abscesses per- 
meate the inflamed portion of the bone. Whatever the color of the con- 
tents, they always, on section, bulge and protrude out of the cavity, and 
pour forth inflammatory fluids mixed with oil-globules. 

For the mere fact of an unyielding bone case being hypersemic, i.e., 
containing an abnormal quantity of blood, cpnnotes that there must be an 
abnormal amount of pressure, and when to this we add rapid formation of 
new products, it is evident that pressure must be very considerable. Hence 
arise venous stasis, or thrombosis, within the cavity, and the singular tran- 
spiration of oil-drops from the medulla through the bone. It is, I believe, 
upon the intensity of this intra-osseous pressure that the greater or less 
destruction of tissue, the more or less virulence of the disease, depends ; 
and the commencement of the second phase, namely, participation of parts 
lying without, the bone, corresponds in a definite ratio with the stasis re- 
sulting from the species of strangulation within it. The extrinsic phenom- 
ena are suppurative periostitis, with phlegmon of the- limb generally ; the 
former is co-extensive with the myelitis, the latter reaches a little higher. 

Suppuration of the periosteum leads very rapidly to abscess both in- 
side and outside that membrane ; but in neither situation is all the fluid 
formed in loco, for it, more especially that beneath the periosteum, is min- 
gled with large oil-globules, evidently emanating from the interior of the 
bone. This fluid is frequently blood-stained, or, when not thus colored, 
is greenish, or may be brown by admixture with the results of bone-de- 
composition. It has, more especially when of the latter hue, an evil, some- 
times a very offensive odor. In the soft parts of the limb, along the course 
of the vessels, and in the intermuscular spaces, large effusion of serum 
takes place ; near the focus of disease this will be intermixed with pus, but 
further away is free of such admixture ; in all but the milder form of case 
it is markedly blood-stained. In the more severe, more pysemic form of 
the disease, thrombosis of the veins occurs, reaching sometimes from the 

merged into simple somatic death of the bone, or, in those parts where this does not 
take place, by gradual re-establishment of the circulation followed by thickening and 
induration (osteo-sclerosis). 



ACUTE ARTICULAR OSTITIS. 201 

smallest radicles to the largest and highest trunks. The clots are fre- 
quently decomposed, and breaking down into ichor-like pus. 

It will be gathered from the above that peracute epiphysal ostitis has 
not only many different degrees of acuity, but that the inflammation itself 
may be of different characters. 

There is no doubt that the description given by Chassaignac ' and by 
Klose ! is highly colored, because those authors only had in view the worst 
and most diffuse cases, such as are comparable to erysipelas or phlebitis of 
' soft parts, such indeed as are also called osteo-phlebitis, and are closely 
related to pyaemia. Such disease appears to be occasionally epidemic, or 
endemic in certain parts of the world ; but fortunately seldom occurs in 
England ; therefore I would merely indicate its morbid anatomy as the 
extreme of what has been described above. Purple hypersemia, large 
blotches of -extravasation and dark-colored pus, occupy the interior of the 
bone, while outside it are found separation of the highly-congested perios- 
teum, which contains, besides, the dead or dying, greenish or blackened 
bone, blood-clots, dark-colored offensive pus, and quantities of oil-globules ; 
the veins of the bone, of the periosteum and of the surrounding soft parts, 
are filled with decomposing coagula, and lie in tissues bathed in ichor and 
blood-stained flocculent pus. 

Even such violent disease as this, however, does not necessarily prove 
rapidly fatal; but under favorable circumstance? the most acute and vio- 
lent symptoms may pass, at or about the end of the second week, into a 
less virulent phase, and may then either end fatally by exhaustion, or give 
rise to amputation in the third or fourth week ; or, on the contrary, may, 
under judicious management, get well by slow degrees. In either case it 
may happen that the epiphysis will separate more or less completely, though 
this is not so necessary a sequence as some authors believe ; but disease of 
a neighboring joint always occurs somewhere between the tenth and twenty- 
fourth day. 

The former of these conditions, though not invariable, is a sufficiently 
frequent occurrence to cause Klose to term the disease " Epiphysentren- 
nung." Its occurrence depends, in a great degree, upon the stress of the 
inflammation falling on the parts immediately next the epiphysal line. 
Sometimes the separation takes place in an incomplete form, a deep groove 
being channelled between shaft and epiphysis — a certain bend or twist 
occurring at this junction, but no absolute disruption. Occasionally, this 
disease is multiple, more particularly when it attacks primarily an epiphy- 
sal junction ; but multiple suppurative osteo-myelitis may occur, whatever 
be the anatomical seat of primary attack. Such cases have been seen by 
several observers, but the most remarkable instance is one related by Dr. 
Demme, of Berne, in which almost every larger epiphysis was separated by 
suppuration at the line of junction (Demme, Wiener Medicin-Halle, 1864). 
The disease, in such instances, commences in one bone, the affection of 
the others is secondary and probably pysemic ; but the relationship which 
causes pysemic conditions to pass from one epiphysis to another, previous 
to affecting internal organs, is quite occult. 

It may be affirmed, with the nearest possible approach to certainty, 
that acute suppurative ostitis of any bone-end never occurs without indu- 
cing some affection of joints. Chassaignac was the first to point out this 



1 Gazette medicale, 1854, Nos. 33. 35, 36, 37. 

s Prager Vierteljahrsohrif t, 1858, to which I more especially referred in my first 
edition. 



202 DISEASES OF THE JOINTS. « 

fact, but he erred in supposing that the proximal joint, that between the 
disease and the heart, was always the one attacked ; the fact being that the 
knee, even if the primary disease he above the middle of the femur, or be- 
low the middle of the tibia, is more often involved than either the hip or 
ankle. At the upper arm the joint nearest the focus of inflammation is the 
one to be diseased. While if the radius and ulna be the seat of inflamma- 
tion, .anywhere above their lower ends, the elbow will be then most com- 
monly invaded. 

In studying the mature of the joint-affections,' which are associated with 
peracute ostitis, we must take care to distinguish those that are primary 
and simultaneous from those that are secondary and subsequent. We 
must distinctly recognize the independence of such rheumatic, traumatic, 
or other inflammations as have been produced by the very same violence 
or exposure which caused the bone disease — inflammations which arise not 
merely at the same time, but may even precede the other malady. These 
conditions were entirely overlooked by the earlier observers (Clmssaignac, 
Klose, Paul J. Roux), who also very much exaggerated the supposed con- 
stant gravity of the secondary, the dependent joint affections — they are 
often comparatively slight, and may, if the bone disease terminate favorably, 
get quite well. Of secondary affections there are several sorts : (1) Serous 
synovitis, produced by extension of inflammation from the periosteum ; (2) 
mere passive serous effusion (not a true hydarthrosis) from pressure on 
and thrombosis of veins leading directly from the joint ; (3) muco-puru- 
lent effusion into the synovial membrane ; (4) pysemic ; and (5) suppura- 
tive synovitis. 

The first three of these scarcely need further comment, their morbid 
anatomy having been already described. I would, however, refer the 
reader to the chapter on Hydarthrosis for a full description of its frequent 
ostitic origin, especially that form which is rich in moss-like growths ; to 
Chapter II. for tlie frequency with which the simple effusion may gradually 
become purulent, etc. — all these may get well either entirely or with a 
small amount of stiffness. 

The next two processes can hardly persist without destruction of the 
joint ; anchylosis, more or less complete, being probably the most favora- 
ble issue possible. Pysemic conditions are not so common at the joint next 
to the focus of disease as they are in those secondarily affected when the 
multiple form of the malady obtains. Suppurative synovitis is produced 
by the passage, into the joint-cavity, of pus and inflammatory products, as 
well as by spread of the disease from the focus of inflammation. The 
irruption of pus into the synovial membrane is not to be regarded in the 
same light as though it took place with great suddenness, as a thunderbolt 
from a clear sky, into a healthy membrane. On the contrary, the inflam- 
mation spreads gradually through the periosteum and cartilage : this latter 
will after a time be perforated, rather might I say punctured, in one or 
more small holes, out of which, at first a little, then more pus distils into a 
cavity lined not so much by highly sensitive synovial membrane as by in- 
flammation-tissue, granulating and inured to the contact of puruloid fluid ; 
or, perhaps, the cartilage is simply shed, detaches itself slowly at one or 
the other spot, with the like result. When separation, partial or total, of 
the epiphysis takes place, the joint may be nearly healthy ; whether this 
occurrence will much affect its condition depends upon the position, inside 
or outside the capsule, of the epiphysal line. Diastasis in itself does not 
affect in any way, save that of position, a joint whose synovial membrane 
is altogether free of the epiphysal junction. 



ACUTE ARTICULAR OSTITIS. 203 

In the course of the disease it is more than probable that some abnor- 
mal mobility of the part will set in : this is accompanied by such deform- 
ity as without due care and knowledge might be ascribed to subluxation, 
which is .not the common, is indeed an unusual sequela of th;s disease. 
The distortion arises from one of two causes ; either from the considerable 
relaxation of ligaments and capsule, produced by the great distending 
force of rapidly accumulating fluids, or from separation of the epiphysis. 
The diagnosis, especially if at a deeply seated joint or greatly swollen limb,, 
is difficult. 

It will be gathered from the above description that recovery is not so 
extremely rare an event as the earlier writers on this subject supposed. 
Of Demme's seventeen cases, 1 seven got .well, and even though pus was 
formed in the affected articulation, it retained fair mobility. Nevertheless, 
the condition is one of great danger ; recovery and convalescence extreme- 
ly slow. 

Beyond the peculiarities above described, the joint-affections second- 
ary to acute ostitis have no anatomical characteristic requiring here especial 
mention. They fall under certain categories as already given (p. 201), 
which are treated each in its proper chapter. 

I have now very briefly indicated the morbid processes which consti- 
tute acute ostitis, especially, if I may so term it, epiphysitis, and have spo- 
ken of more and of less violent attacks. The former belong to that mode 
of inflammation which is closely, indeed in our present state of knowledge- 
inextricably, mixed up with phlebitic, septicsemic, or pyeemic phenomena- 
Such cases, the only ones observed or noticed by Chassaignac and Klose, 
led them erroneously to consider the one as necessarily involving the other. 
The fact is, however, that all grades of osteo-myelitis exist ; and I have no 
hesitation in saying that many cases of very circumscribed and localized 
nature are occasionally entirely overlooked ; the symptoms being obscure 
and sometimes impossible of interpretation. They end, if their course be 
favorable, in gradual readherence of the periosteum by granulation-tissue, 
sprouting from that membrane and from the subjacent bone ; and by in- 
spissation and enclosure within sclerosed bone of the intra-osseous pus de- 
posit, sometimes also of a sequestrum. Such desiccated pus may remain 
thus encapsuled and dried up for many years, perhaps permanently. But 
when a subsequent disease (and bones thus weakened by old inflamma- 
tions are very prone to new attacks) reveals to examination the ancient 
casified abscess, it is generally mistaken for a tubercle ; and the more 
plausibly, if instead of one such blotch there be several small remnants of 
pus-deposit (chaplets of abscess, p. 202) scattered through the spongy tex- 
ture. If, however, an ostitis, though still belonging to the less violent 
class, have yet gone far enough to set up large pus-deposits, and to have 
caused considerable necrosis, death, though delayed, may yet occur either 
by pyaemia, after joint-suppuration and deep-seated, abscess in the soft 
parts, or by exhaustion, with lardaceous degeneration of kidney and liver. 
If the unfortunate patient escape with life it will only be after lengthened 
illness, separation of dead bone, and destruction of much tissue ; he will 
bear to his grave a crippled and weakened limb ; or perhaps, if the ulti- 
mate resort of surgery have saved his life, an amputation stump. 

Symptoms. — The first sign of acute osteo-myelitis is generally a rigor, 
closely followed by severe pain in the affected limb. Occasionally a dull 
but rapidly increasing pain of a limb precedes all other symptoms by a. 

1 Loo. cit. 



204 DISEASES OF THE JOINTS. 

certain number of days. Sometimes it is possible, sometimes impossible, to 
trace the attack to such cause as a severe blow or long-continued exposure 
to cold ; sometimes it would seem that an endemic influence prevails, 1 and 
when such causality is to be recognized, diagnosis is facilitated. The pain 
is described by patients somewhat differently, either as burning, lancinat- 
ing, violent aching, bursting or throbbing. It is accompanied by a very 
significant loss of power in the part ; the limb remains utterly immobile ; 
if the patient be told to get higher or lower in the bed, he does so with 
groaning difficulty, and either drags the limb by the trunk or lifts it with 
his hand. Independent movement of the member itself seems impossible. 
At this time, and for from three to eight days afterward, no change what- 
ever can be detected by local examination ; but the fevered state of the 
patient, with marked evening exacerbation, reveals serious disease. The 
temperature varies from 100" to 105°, or even more ; it may have been pre- 
ceded and accompanied by rigors, the pulse is at an average of 120 to 140, 
the tongue is furred, and appetite quite absent. There is entire sleepless- 
ness, and generally delirium. At first the bowels are usually constipated, 
afterward vomiting and diarrhoea accompany the worst cases. 

Some time within a week after the appearance of these characteristic 
symptoms local swelling becomes manifest ; it is of doughy consistence and 
^edematous near the surface, but hard beneath ; the induration ceases in a 
hard, sudden edge — the limb beyond this being to touch normal, or nearly 
normal. The tumefied part is very tender on deep pressure ; but this ten- 
derness ceases at the above-mentioned edge, as sharply and as suddenly as 
the swelling itself. This abrupt line of cessation is a very marked symptom 
upon which Chassaignac laid great stress, and very rightly, even although 
it may occasionally be absent. For some days, even as many as from five • 
to nine, after the first appearance of tumefaction there is neither change in 
the color nor in the local heat of the skin. This change, according to 
Demme, 2 only supervenes when the deep swelling, the periosteal abscess, 
has approached the surface. In one of the cases I have seen, the coloration 
when it came on was red, the surface glazed, and the veins strongly marked ; 
the subject was very young ; both Chassaignac and Gosselin 3 observed the 
same hue ; but Demme, whose experience on this subject is large, says that 
' as long as the acute oedema of the integuments continues — and in the phle-, 
bitic form it may last throughout the disease — the color is a dirty clayey 
pallor, on which the veins are marked out with more or less distinctness. 
Abscess is not generally to be detected till toward the end of the second 
week, but in some cases is earlier. 

Altogether the disease, when thus fully developed, is distinctly recog- 
nizable ; the pain and helplessness of limb, accompanied by well-marked 
pyrexia, preceding any swelling by not less than three, more often by five 
or six days ; then the rapid advent of deep, hard tumefaction, usually with 
a sharp edge and evidently sessile on the bone — absence of coloration for 
several days after detection of swelling — form altogether a picture so dif- 
ferent from that of phlegmonous cellulitis or erysipelas that mistake is 
hardly possible. But Chassaignac advises that for diagnostic purposes a 
wide incision should be made through the soft parts and periosteum to 
the bone, and that judgment might be aided by the presence of oil-globules 
floating in blots upon the surface of the pus. Such proceeding, merely 
for the purpose of diagnosis, is a somewhat trenchant measure, especially 

1 Such appears to have been present in Klose's cases. 

2 Iioc. cit., p. 245. 3 Arch. gen. de med., November, 1858. 



ACUTE ARTICULAR OSTITIS. 205 

as oil-globules may be present in certain other diseases. "Whether such 
aid to diagnosis is to be entirely rejected depends upon whether it be a 
valuable or injurious adjunct to treatment, a matter to be considered in 
the sequel. 

One of the results of osteo-myelitis, namely, separation of the epiphysis, 
is not of itself a phenomenon dangerous to life ; but the disease producing 
it may by its virulence be necessarily fatal, and may receive a further lethal 
impulse from such occurrence. This destructiveness corresponds roughly 
but pretty accurately with the rapidity with which diastasis is produced. 
In the severe osteo-phlebitis observed by Chassaignac, Klose, and J. Boux, 
the epiphyses separated about the tenth or twelfth day. The sudden as- 
sumption of a new abnormal posture, and the deformed appearance about 
the joint, first aroused suspicion of the fact. In such cases the soft tissues 
are" very liable to become gangrenous, and to permit the protrusion to some 
little distance of the ragged, brown-green, and semi-putrescent shaft-end of 
the bone. 

In other cases ' separation was delayed until much later, viz., up to the 
40th or 55th day ; under such circumstances it may be, as I myself have 
seen, only partial. 2 The symptoms are similar to fracture at a later age, 
that is, after the epiphyses have joined, for it need hardly be pointed out 
that diastasis can only occur at an early period of life. Distortion, which 
careful examination by eye and touch will show not to arise from dislocation ; 
abnormal mobility, while the shape of the joint can be felt to be unchanged 
by the movement — i.e., the relative position of the joint-ends remains the 
same ; while abnormal lateral movements near a hinge-joint, such as the 
knee, are enforced, there will, for instance, be no divulsion of joint-surface, 
no opening and shutting of the articulation. The truncated shaft-end makes 
pressure from within toward the skin, giving rise to a certain amount of 
prominence, which may be felt to be different in shape to that of the joint- 
end. These peculiarities can be much more easily made out in a subject 
who33 soft parts are normal, than in one whose tissues are swollen by sup- 
puration and oedema. Moreover, a minute knowledge of the shape of dia- 
physal and epiphysal junctions in different bones and at different periods 
of life greatly aids diagnosis. Nevertheless, in the particular conditions 
whereby osteo-myelitis may be recognized, the attendant naturally looks 
for diastasis ; therefore, if any distortion and abnormal mobility come on, he 
will hardly fail to recognize its cause, more especially since in all but very 
young subjects, babies in fact, some crepitation, in part hard, in part soft, is 
present. Not unfrequently also a sinus or abscess— opening leads a probe 
direct to- the line of separation : occasionally the edges of the disjunction at 
one part (diaphysal) or the other (epiphysal) can be felt. It should be 
known, though the matter is hardly connected with my present subject, 
that not merely do joint epiphyses, but also muscular apophyses thus be- 
come separated from the shaft. 

Affection of the joint lying near the osteo-myelitic focus manifests itself 
in different ways. Chassaignac was not correct in imagining that it always 
assumes a violent suppurative character ; moreover, he only mentioned that 
form which is directly induced by contiguity to the bone disease. . If, how- 

' Demme, 1. c. ; Roser, Die paeudo-rheumatische Knochen und Gelenk-Entziindung, 
Archiv fur Heilkunde, 1865. 

8 II is well to point out that diastasis may occur from other causes besides osteo- 
myelitis, for instance, suppurative periostitis, even suppurative synovitis may produce 
it in those bones whose epiphysal line lies within tho capsule of the joint ; tr.iumatio 
diastasis is of course well_knowiuto_every_DracticaLsurgeon. 



206 DISEASES OF THE JOINTS. 

ever — and thii* I have observed when the patient is between the third and 
sixth year — the disease originate in injury, a tolerably well-marked simple 
synovitis may precede a graver affection. Later in life, when exposure to 
cold has produced the disease, a sharp rheumatic synovitis may first arise 
and will tend to distract attention from the earlier symptoms of the osseous 
malady. The mixture of the two diseases is indeed sufficiently perplexing, 
for the surgeon having in his mind a synovitis, perhaps not markedly severe, 
sees in that malady not enough to account for the severe pain and the great 
pyrexia, especially as in the first few days of the more important disease, 
the joint may evidently be getting better. Again, a less early, but still 
early, synovitis, of rather a slight character, may be caused by extension of 
inflammation from the periosteum, while that membrane, only just com- 
mencing to feel the force of the disease within the bone, is as yet but slight- 
ly involved. Such symptoms, combined with the signs and the history of 
an ordinary synovitis, may very excusably lead the surgeon to attribute the 
pyrexia and pain to a wrong cause, and to diagnose the case as one of acute 
suppurative synovitis. "When the hip or shoulder is affected the distinction 
is more difficult than when the knee or other superficial joint is involved ; 
the differential signs are as follows : The pain'is differently placed ; osteo- 
myelitis, however near the joint, does not produce pain within it, nor in 
the spots characteristic of synovitis, but in the bone itself, a little distance 
from the articulation, even when the epiphysis is primarily involved. The 
joint is less swollen, and on its surface cedematous ; it is also less exqui- 
sitely tender than a suppurating one ; tenderness may indeed be detected 
over one of the joint-bones, but is quite or almost absent from the other ; 
it often is more marked a little distance from the joint than over the synovial 
membrane itself. The surface is not red, nor are, in these early days, the 
veins upon it strongly marked. Lastly, the characteristic positions of severe 
synovitis are absent ; the knee, for instance, does not become more and 
more flexed, but remains almost straight, until after the fifth or eighth day, 
the period when the deep hard swelling of osteo-myelitis occurs. These 
are very peculiar conditions ; the patient has a strongly marked pyrexia of 
a somewhat typhoid form, and complains of severe pain in an extremity — 
a joint in that limb is affected, but to a degree only which cannot possibly 
account for the general disturbance. The pain points to local disease, the 
violent fever marks its severity, but the joint-affection is not severe ; this 
peculiarity of symptoms can be interpreted in but one way : the surgeon is 
at once led to regard the bone in the neighborhood of the joint as the seat 
of disease. 

The secondary joint-affections, those depending directly on the osteo- 
myelitis, have been described as of five orders, and any one, even the mildest 
of these, may be present when the bone is already suppurating ; they only 
arise after the bone disease has been for some time established, and then in 
a gradual, almost imperceptible manner. The first three manifest them- 
selves by the ordinary signs of fluid in the articulation ; but it will always 
be very difficult to verify a transition from mere serous to purulent synovitis, 
since one of the chief symptoms of this change, viz., pyrexia, is masked by 
fever already existent. The diagnosis is, under the circumstances, unim- 
portant, but should the surgeon wish to make it, an aspirator needle will 
readily solve the question. 

Pyaemic pus-deposit manifests itself by the general signs of that dyscrasia 
rather than by any especial local ones ; if the joint have not been previously 
affected it will of course swell after the manner described at p. 65. The 
joints of the limb itself, especially the joint near the original disease, are 



ACUTE ARTICULAR OSTITIS. 207 

less likely to be attacked by metastatic abscess than distant ones. In mul- 
tiple osteo-myelitis such condition of a distant joint is the first sign that a 
new focus of disease has formed. 

Acute suppurative synovitis, as a sequela of acute ostitis, unless under 
mistaken forms of treatment, is rare ; its symptoms are very distinct. Occa- 
sionally, such disease is ushered in by considerable decrease in the pain 
above the joint, owing apparently to some decrease of intra-osseous pressure 
— pus having escaped into the synovial cavity. This slight remission is fol- 
lowed by a renewal of rigors, which have for some days been absent ; then 
follow fresh pains, a new rise of temperature, rapid swelling of joint with 
redness of surface, and the other symptoms described at p. 203. The usual 
form of joint-suppuration in these cases comes on slowly, and is much 
masked ; the punctured openings, one or more in the cartilage, being filled 
by granulations from the cancelli, let pus pass but slowly into the joint ; 
hence, already inured to its presence by previous thickening and hardening 
of the synovial tissue, the suppuration is less stormy than under other cir- 
cumstances ; it is therefore less pyrogenous, and in a given time less de- 
structive ; but the same signs as those above given, though not so severe, 
will show the character of the disease. 

Treatment. — When, in 1854, Chassaignac read before the Academie des 
Sciences his since classical papers on Osteo-myelitis, he also described the 
treatment, namely, early and wide incision down to the bone. Only two of 
his cases recovered. Klose, J. Roux, Gosselin, and others followed in the 
same line, and with very similar results. Whether, after this incision, am- 
putation was or was not performed, the patients, as a very general rule, died. 

In 1862, Dr. H. Demme, of Berne, published his paper on this subject ; ' 
he gives the detailed history of seventeen cases. In the first four Chassaig- 
nac's recommendation was carried out ; they died on the 15th, 34th, 76th, 
and 138th day respectively. In the other thirteen cases no early incisions 
were made ; of these every one recovered. 

It is, doubtless, sad and humiliating to consider that in memoirs un- 
doubtedly careful, and founded on minute observations, excellent surgeons 
should have inculcated and inaugurated a treatment that, in great degree, 
produced the sadness and blackness of the picture which they drew. But 
there can be no doubt of the fact that incisions which opened but to the air, 
and its floating influences, veins already inflamed, and prone to septic action, 
admitted that particular morbid agency which should be carefully excluded, 
and which there can be no doubt were, in many of these cases, the cause of 
death. The fundamental axiom of Dr. Demme's treatment is therefore to 
avoid making any opening whatever, during the more violent phase of the 
malady which, as previously stated, passes away some time during the sec- 
ond week, leaving a subacute and less dangerous condition. 

Dr. Demme, moreover, supports this view upon theoretical grounds, point- 
ing out that the malady and the abnormal pressure lie within the bones, be- 
yond the reach of the knife, and that merely to cut down to its surface can- 
not relieve the evil ; also, that the wide and deep incisions so strongly 
recommended by the authors already frequently named, give rise to very 
considerable bleeding, and that in the depressed state of the patient it is 
absolutely necessary to spare his powers in every way. 

During the brunt of the febrile condition he recommends therefore a 
somewhat expectant treatment. The diet to be nourishing, but light and 
unexciting. The use of morphia and other anodynes is absolutely necessary. 

1 Loc. oit. 



208 DISEASES OE THE JOINTS. 

Beyond this, the medicinal treatment is to be as simple as possible, though 
naturally, in the course of such a malady, various indications for different 
forms of medication may arise, such as diarrhoea, constipation, icterus, pleu- 
ral complications and the like. 

For local treatment the most necessary condition is entire rest of the 
limb, which should be somewhat raised. An Amesbury splint, for instance, 
swung in a Salter's cradle, or the suspension arm-splint (see p. 55). Any 
local bloodletting, poultices, etc., are to be repudiated. Two applications 
more especially seem to him commendable, viz., ice in bags kept constantly 
on the limb, and iodine painted on every two days. Of the former he has 
had no personal experience. 1 The latter is his sheet-anchor; indeed, Dr. 
Demme speaks of this application not merely in this disease, but also in 
others, in terms which English surgeons will hardly endorse. He uses a 
very strong tincture, namely, of pure iodine, 60 — 68 grains to the ounce of 
nearly absolute alcohol (96 — 98 per cent.) ; this preparation is to be painted 
on till a blue-black color is produced, and always beyond the limits of the 
disease. The part then is to be covered in cotton-wool or wadding, or in a 
compress steeped in oil. If it should blister, acetate of lead, alum or an 
opium lotion is to be applied. 

If any abscess come near the surface, it may be opened by a small valvu- 
lar incision, or by a trocar ; the surgeon will, of course, take this opportu- 
nity of confirming his diagnosis by looking for the characteristic circles of 
oil floating on the pus. "With this treatment we must wait for the gradual 
decrease of pyrexia and of inflammatory signs, which usually come on in the 
second week. 

The subacute phase of the disease, when fairly developed, is the' signal 
for incisions, or at least for an opening through the skin ; the place must be 
determined by the proximity of pus to the surface. The scalpel gives rise 
to much loss of blood — the actual cautery, or chloride of zinc, is, according 
to Demme, preferable, and even when the knife has been used he recom- 
mends subsequent cauterization. Afterward, the wound is to be washed out 
with injections of chlorinated water and iodine ; or dressings with plugs 
soaked in tincture of iodine, so as to convert the soaked and dying areolar 
tissue into a dry slough. If any symptom indicate that within some part 
of the bone a collection of pus has taken place, the trephine may with ad- 
vantage be applied. 

Thus far I have given the views of Dr. Demme the younger as opposed 
to those of Chassaignac, Gerdy, and others. At the same time I must sub- 
mit that in certain cases tension is so excessive that incision, unless he would 
allow gangrene to come on, is forced upon the surgeon. Moreover, we now 
have means whereby the advantages of opening may be attained, without the 
fear of putrefactive changes ; and of the only cases which I have had to 
treat since I commenced the antiseptic method, two got well rapidly, after a 
limited incision followed by free tearing of the periosteum ; one died, ampu- 
tation being declined, of lardaceous disease and marasmus. I would, under 
our present advantages, incline to follow this course. Of the two cases which 
I treated after Dr. Demme's method, the more severe one died, the other 
recovered, but with considerable necrosis and a stiff, somewhat deformed, 
joint. As to the general treatment, plentiful support, large doses of quinine, 
or, under fear of purulent infection, the sulpho-carbolate of sodium (see p. 
81) are necessary. Morphia most conveniently as a hypodermic injection 
is, as already stated, essential. 

1 My own has been highly unfavorable. 



ACUTE ABTICULAR OSTITIS. 209 

Even after the patient has convalesced, certain very troublesome condi- 
tions generally remain behind, and may continue for years. Sequestra will 
probably be left, which, if large, may even prove a source of subsequent 
danger — if small, may keep open long, tortuous sinuses, leading outward 
through the skin, and maintain a continual discharge, with more or less of 
pain and lameness. Also, if the, closure of veins by phlebitic thrombosis 
remain permanent, a very troublesome oedema, with solid effusion, impairs 
the function of the limb. These must be treated according to the circum- 
stances of the case, and to the precepts of surgery, to inculcate which is 
not my present task. But I must point out that a bone thus weakened by 
an osteo-myelitis, is very prone to subsequent forms of disease, which we 
shall meet with in an ensuing chapter. 

The management of diastasis is two-fold ; the preventive and the cura- 
tive. Every surgeon encountering the disease above described will be pre- 
pared for such occurrence ; he will, however, remember that only in the 
worst, the osteophlebitic forms, are the epiphyses cast off in a rapid, almost 
sudden manner. That in general a groove more or less deep, and extend- 
ing either entirely or partially round the bone, gradually invades the epi- 
physal junction more and more, until it is entirely absorbed, or until a check 
is put to the absorbing process. If any violent or sudden movement occur, 
while the formation of this groove is somewhat advanced, the lessened bond 
between shaft and joint-end will snap ; while if by due care such occurrence 
be rendered impossible, the union may be maintained. The limb, then, in 
all these cases must be entirely immobilized, nor rnust even a slight chance 
of movement be permitted ; care of course will be taken that the joint be 
put up in such position as will be most useful should the very probable an- 
chylosis ensue. 

When diastasis has taken place anchylosis is the best attainable result. 
The accident must be treated like a fracture, but even with more rigid main- 
tenance of immobility and for a greater length of time. A false joint about 
the elbow may be tolerated, but one at the knee is a very grave misfortune, 
arid years of splintage can hardly be called wasted if they at last overcome 
the trouble. As soon as the condition of soft parts permits such applica- 
tion, a plaster-of-Paris bandage, in which openings at the sinus mouths are 
cut, is the best form of support. Afterward a well-fitting mechanical ap- 
pliance may be necessary. 

As the diseases of joints combined with osteo-myelitis are of manifold 
degrees and kinds, so must the treatment be various. The primary malady, 
that which I have described as produced by the same cause as, but other- 
wise independent of, the osteo-myelitis, assumes the form of acute serous or 
suppurative synovitis, which sometimes even may be severe, and if it pre- 
cede the inflammation of bone will engage all the surgeon's attention. The 
treatment of acute synovitis described at p. 38, which is here appropriate, 
will, in a certain number of cases, subdue the malady before or very soon 
after the manifestation of the bone disease. In other cases the two mala- 
dies arise simultaneously or nearly so ; the primary joint-affection is very 
apt to persist long enough to mingle with a fresh and secondary inflamma- 
tion, propagated from the bone. Under such circumstances very rapid and 
considerable exacerbation takes place ; the symptoms are not so much ag- 
gravated as muffled and concealed by a more violent condition, hence a 
frequent difficulty in apportioning its just part to either phase of the treat- 
ment. I would recommend more especially, besides rigid rest, free vesica- 
tion, either by the Spanish fly or the strong tincture of iodine, not over, 
but rather above the joint, and close watchfulness as regards tension of 



210 DISEASES OP THE JOINTS. 

parts. When the synovial membrane and the perisynovial tissues get full 
and tight, an incision should be made under the most rigid antiseptic pre- 
cautions. A subcutaneous incision, unless we can be quite sure that the 
fluid is not pus, and unless the joint only, not the neighborhood, is tense, 
■will either lead to extra-articular abscess, or will not relieve the condition. 

Case LV. — Mrs. F. brought her baby, aged two years and three months, 
to the hospital, April 14, 1867. The child, though at the time very ill, 
-was of fine, vigorous growth, and evidently of excellent constitution. The 
mother suspected, but could not affirm, that it had been let fall by a girl in 
•charge about a fortnight previously — the symptoms appeared to have com- 
menced eight days since. The- right thigh was greatly swollen, red and 
shiny on the surface. The tumefaction was hard, on deep pressure the 
superficies cedematous, the red color disappearing on the place of pressure, 
and only slowly returning. The tongue was rather brown, the skin hot and 
■dry, the child's manner oppressed and dull. Mr. Hancock treated the 
■child by poultices and purge, support and stimuli. 

April 18th. — The limb, which previously had been bent up, was found 
to be straight, evidence of an abscess appeared in the lower third of the 
outside of the thigh ; this was opened, the finger passed in, and the deeper 
parts torn away. A good deal of pus, with oil-globules floating on it, were 
thus evacuated, and I felt the femur bare throughout the whole extent oi 
the wound. 

April 20th. — The limb was found in a very strange position, the knee 
hyper-extended, hollow in front above the patella, protuberant in the poplit- 
eal space. The tibia was not in a straight line with the femur, but was 
directed considerably outward. The child was apathetic, almost comatose. 

April 23d. — Early on the morning of this day the child died. 

April 25th. — Leave to examine the limb only was with difficulty obtained. 
The skin being carefully removed, the saphenous vein was found to be 
choked with thrombus, as far as the saphenous opening. The tissues out- 
side the fascia lata were somewhat infiltrated by serum of brownish hue. 
This fascia was divided from knee to groin. The muscles were of remark- 
ably dark color, the interspaces filled with serum in the upper parts ; lower 
down, i.e.,. nearer to the knee, this fluid gradually changed to a brownish 
and then blood-stained pus. The veins all contained clots, some of which 
were evidently old and broken down, being of a dusky yellowish or fawn 
color. This was more readily made out in the larger veins, therefore es- 
pecially in the femoral, but they were all apparently in the same state. 

The periosteum was separated from the femur in the lower half of the 
bone, which was rough and necrosed, the interval left being occupied by 
thick, rather grumous pus, and oil or liquefied fat. On the inner and front 
part of the diaphysal end, the bone was rough and excavated, there being a 
hollow as large as half a filbert, with very uneven surface, looking as if it 
had been gnawed. This caries extended along the epiphysal junction, which 
was quite destroyed except at the back and outer part, where some carti- 
lage-fibres still kept the epiphysis attached to the shaft. The epiphysis 
itself was roughened by the deposition of small, uneven osteophytes, but 
though inflamed was not necrosed. I could not, owing to the promises 
exacted by the mother, remove the femur, but made a longitudinal section 
with the saw, so as to open the medullary cavity from the end of the dia- 
physis upward for about four inches. This cavity was filled with pus- 
liquefied medulla and blood extravasations ; these last did not mingle with 
the other fluids, but were clotted in different parts, so as to give a singular 



ACUTE ARTICULAB OSTITIS. 211 

coloration ; varied of yellow, dusky and bright, brown verging into green, 
and purple. The inner layer of bone-tissue, that forming the wall of the 
medullary cavity, was here and there soft — rough-looking, as though worm- 
eaten ; occasionally a larger hole than usual contained a soft pultaceous 
plug. 

Case LVI. — John C. r aged thirteen, received, February 2, 1871, a severe 
kick on the outer side of the left thigh while playing foot-ball. He had, for 
some days, a good deal of pain, in about a week this seemed better ; but he 
felt ill. On the 12th or 13th he tried to run home through a shower, but 
this hurt him so much that he stopped, and had to go slowly, and got very 
wet. Three or four nights after he was awoke in the night with violent pain 
and headache, was sick next day ; the limb was swollen. 

February 17th. — He was brought to the hospital. The outer side of 
the thigh was baggy with fluctuation, the whole limb swollen ; although 
the superficies was soft, and the case seemed like an abscess under the 
fascia lata, stronger palpation showed that there was a deeper, harder swell- 
ing, sessile on a portion of the bone. The limit of this indurated part was 
very defined ; below being about two inches above the patella ; above about 
the junction of the upper, with the middle femoral third. The limb lay 
quite straight on its back ; he did not move it when told, though evidently 
he tried to obey. I asked him to get up higher in the bed, and while doing 
so he dragged the limb along as though it were quite lifeless. There was 
no redness, but rather a pallor of surface. Several tortuous, mesh-like 
veins were strongly marked above the knee-joint, and running up the inner 
side of the limb. Tongue brown and dry ; pulse, 130 — 140, small ; temper- 
ature, 104.8°. Occasionally, especially at night, the boy had a muttering 
form of delirium ; sometimes very restless, but more commonly was duU 
and apathetic. He was, on admission, either already affected with pysemia, 
or on the verge of being so. The abscess was incised only through the 
fascia lata, a great quantity of pus escaped ; it contained no oil-blotches, 
but had a somewhat offensive odor ; the cavity was mopped out with chloride 
of zinc solution, and the wound dressed with permanganate of potash. 

February 21st. — Very plentiful discharge from the wound ; the pus con- 
tains some oil. On passing in my finger I felt the periosteum baggy and 
fluctuating ; also I detected a small opening, into which I passed a strong 
steel director, and tare the membrane almost to the extent of the outer 
opening. The limb looked rather deformed at the knee. A light Maclntyre 
splint applied, limb swung. The pus, which flowed freely, contained a 
quantity of oil. The boy's health was much in the same state ; the ther- 
mometer, however, marked a few decimals less temperature. 

February 24th.— The swelling of the thigh had decreased ; the bone 
could be felt bare and rough as far as the finger would reach. The boy is 
more restless, mutters continually, sleeps little, but seems often comatose. 
Some diarrhoea ; stools very offensive and dark. 

February 27th. — The limb decreased in size ; but with a singular yellow- 
gray hue over the whole thigh. The boy, however, was worse, his breath- 
ing very quick and shallow ; tenderness over the abdomen. Pulse almost 
too quick to be counted ; temperature, morning, 100.2° ; evening, 105.1°. 
March 1st. — Death took place in the night. 

March 3d. — Post-mortem. Secondary pyaemic deposits in both lungs, 
but chiefly in the left, a few secondary abscesses in the liver — a low form 
of peritonitis — intestines contracted. Brain pale, with much serum in cav- 
ities, no abscesses, a little arachnitis in Sylvian fissure. The thigh infiltrated 
with turbid -s a riim nnrl nna flip mnanioa Aav'b and softened, breaking under 



212 DISEASES OE THE JOINTS. 

pressure with the finger. All the lower half of the femur bare, the perios- 
teum filled with thick grumous flocculent pus, offensive and of a greenish 
hue. The lower end of the diaphysis was of a deep brown color, and the 
neighborhood was saturated with oil ; the epiphysis was quite detached, and 
the truncated end of the shaft was very rough ; from this darkened part of 
the bone the necrosis seemed to have spread upward, but much more ex- 
tensively on the outer than on the inner side — the line of attachment of the 
periosteum being very oblique. On splitting the bone, lengthwise, with the 
saw, one opened close to the lower part of the shaft an intra-osseous ab- 
scess, and when the section was complete this was found enclosed in fairly 
smooth osseous walls, of a green, almost bright green, hue, which on the 
section edge could be seen to merge into brown toward the outer surface. 

The veins of the limb were mostly choked with thrombi and broken- 
down clot. 

Case LVII. — Emma S., aged eleven, admitted under my care into Char- 
ing Cross Hospital, November 5, 1875. She was taking home work for 
her mother ; met with no accident that she knows of — but the distance was 
considerable ; she was very tired, and had to sit down several times ; came 
home late and had no supper ; felt very bad, and did not sleep. Had to 
get up next morning, but could hardly walk from pain in the leg. This 
happened a week before she came to the hospital. 

She was a small, ill-nourished ,girl, of feeble constitution, not properly 
fed, and evidently hard-tasked by her mother. The left leg was swollen 
and very painful ; the swelling was chiefly just below and about the knee- 
joint, where considerable deep indurafion could be felt, but the whole limb 
was oedematous and marked by a network of tortuous veins, except at a 
spot inside the tubercle of the tibia, which was red ; the limb was of a 
muddy yellow color. It was quite helpless, as though paralyzed. Her 
tongue was white and coated slightly brown by the raphe ; pulse, 125 ; 
temperature, 103.8°. Support and stimuli were ordered ; also a sufficient 
purge. Hypodermic injection of morphia. Limb to be wrapped in a tur- 
pentine stupe. 

November 8th. — The limb was more swollen; the knee-joint fluctuating. 
A small incision was made through the periosteum on the inner side of the 
tubercle, where the red spot above-mentioned had become of a dusky 
color, pus escaped. The finger passed in felt that the bone was bare, and 
that the periosteum was detached for a further distance. I followed with 
finger and knife this detachment, at last as far down as about three fingers' 
breadth from the ankle-joint. This was done under antiseptic precautions, 
a piece of gauze was placed in the wound, and dressings after that method 
applied ; the limb placed on a Maclntyre, and swung in a Salter cradle. 

November 10th. — The leg less swollen and of a better color ; veins less 
strongly marked ; the knee more swollen and painful. Wound discharging 
freely, but looked healthy ; temperature on night of 8th and 9th, 102.4° and 
-101.2° respectively. 

November 13th. — Leg much better ; knee more swollen and fluctuating , 
tried to withdraw fluid by aspirator ; only got a drop or two of turbid serum 
or liquor puris ; passed a long tenotome from upper corner of tibial wound 
under the skin along inner margin of patella, and, while withdrawing, 
opened synovial membrane very freely ; an abundance of flocculent pus 
flowed away ; put into wound a small drainage-tube, directed it to be 
shortened by one-half on the third day. 

November 16th. — Girl very much better ; temperature the last two 
nights under 100° ; tongue cleaner ; begins to eat welL 



ACUTE AKTICULAR OSTITIS. 213 

February 4, 1876. — The patient went on uninterruptedly well. In the 
beginning of January passive movement was tried on the knee, but she had, 
somewhat to my surprise, very little restriction of motion and scarcely any 
roughness, which soon disappeared. Tbe wound over the tibia had healed, 
leaving five sinus mouths, which led to bone. She went to a convalescent 
home, with orders to return if sinuses remained open. 

May 2d. — Returned as agreed, only one of the sinus mouths had closed, 
the rest led straight to bone. One high up, one about upper fourth, and 
one quite low down in the leg. 

May 4th. — Under chloroform, and antiseptically laid together the upper 
sinuses ; found periosteal bone rather thin and soft enclosing sequestrum ; 
' cloacae here and there. Had to lay open the whole of the old wound, turn 
new bone forward and backward with periosteum, cut thrpugh the old tibia 
above and below and remove it, clearing away at either end until coming 
to live osseous tissue ; the dead'did not reach quite to the lower, but fully 
to the upper epiphysis. The girl made an excellent recovery ; the bone 
being reproduced a little thicker and larger than the normal one. The 
sequestrum is in the Museum of the Charing Cross Hospital. 

Case LVHI. — Thomas F., aged five months, was brought to me at the 
Charing Cross Hospital, June 15, 1878, with greatly swollen shoulder and 
arm. The child had been quite healthy until five days ago — when it was very 
fractious — screamed if in dressing it the arm was moved ; an injury was sus- 
pected by the mother ; only, however, because she could not otherwise 
account for the condition ; temperature, 103.4°. She refused to come in 
with the infant or to leave it, it was treated therefore as an out-patient. 

June 20th. — The child brought again ; arm more swollen ; child pale 
and apathetic — mother stayed in with the infant — which, however, was evi- 
dently dying, and it succumbed in the evening of the day after. 

Post-mortem Examination. — With difficulty I obtained permission to 
examine the joint only. This was laid open by a V-incision. The long 
head of the biceps had disappeared ; the synovial membrane was full of 
thick creamy pus, but was only slightly reddened. The cartilage was full 
of holes, larger and smaller, all of which led straight to the osseous nucleus, 
and from all of which pus flowed. The cartilage was cut through with a 
knife, and on opening it the nucleus fell out of a cavity, still partly full of 
pus. All the cartilage was abnormally vascular, but the immediate lining 
wall of the cavity was excessively so ; and in parts the vessels formed a 
sort of lining not unlike the pia mater. The nucleus itself was pale yellow, 
friable and necrosed. 



CHAPTEK XL 

CHRONIC OSTITIS. 

Pathology. — Ostitis is described as of different sorts, according to the 
condition which" produces it ; thus there are the traumatic, rheumatic, stru- 
mous, syphilitic, and some other varieties, -any of which maybe more or less 
acute, more or less chronic. Moreover, though fundamentally similar, the 
action is rather different according as it occurs in the hard solid texture, 
or in the cancellous tissue of bone ; and this latter presents in early life, 
while the part is still chiefly cartilaginous, certain peculiarities, which, for 
our present subject, are of great interest. It will be remembered that in- 
flammation of the shaft of a bone, though it may occur at all ages, is unu- 
sual (save as acute osteo-myelitis) in early life. Ostitis of spongy tissue, 
if it affect a short bone, is common to early and adult life ; but affecting 
the epiphysal end of a long bone, is, as a primary disease, almost confined 
to childhood. 

Even further distinctions must be drawn according to the particular 
histological changes which inflammation produces. I do not mean the 
termination of the process, as in caries or necrosis, but the forms of the 
action itself — these are chiefly the rarefying or osteoporotic, also called 
malacissans, i.e., productive of malacia ; and the indurating process called 
osteo-sclerosis. 1 Our subject will best be elucidated by first describing 
the rarefying type as it occurs in spongy, then in solid portions ; afterward 
the condensing variety. Furthermore, we must examine the peculiarities 
of the process arising in immature short bones or epiphysal ends ; lastly, a 
few words must be said about the terminations of inflammation. 

A section made with a fine sharp saw through a cancellous bone, in an 
early state of inflammation, shows, among the yellow toned or slightly pink 
medulla, spots or blotches of redness, from which oozes, as a rule, some 
oily, creamy serum, which generally moistens and adheres to the instru- 
ment. These spots are of greater or less size according to the severity of 
the case, and in some degree also according to its age, for that which a few 
days previously might have been found as a speck may at the period of 
section have' increased to a great blot ; it may, if the inflammation be quite 
diffuse, involve the whole epiphysis ; or, if sharply circumscribed, may be 
surrounded by a more or less complete ring of cancellar tissue, rather 
whiter, harder, and more solid than the norm. The red blotches are some- 
times, but this in the more rapid, especially in the traumatic form, speckled 
with little spots of extravasation ; in such case there is more than the usual 
amount of serum, which also is blood-stained. Section, made a little later, 
displays besides a deeper coloration a singular enlargement of soft parts, 

1 I shall here confine myself to these forms, although in reality there are several 
others, as yet but little understood and very difficult of elucidation ; thus ostitis de- 
formans of Paget (Med. Chir. Trans., vol. lx.). Arthritis deformans, probably rachitis, 
are different forms of slow inflammation of bone-substance. 



CHRONIC OSTITIS. 215 

manifested by their protrusion beyond the section-surface of the cancellar 
walls ; that is to say, that out of each cancellus, cut across by the saw, there 
pouts a little plug of soft material, which previously was compressed within 
that cavity. As such projection takes place out of each cancellus all the 
affected part feels to the finger drawn across it like a piece of velvet ; and 
the bone is not detected at all unless pressure enough to put aside or crush 
down these excrescences be made. This condition depends upon the fact 
that under the influence of inflammation the contents of each cancellus be- 
comes too large for the cavity. Part of this contents is a serous or sero- 
sanguinolent fluid ; but in this form of ostitis the bulk of it consists of gran- 
ulation-tissue formed by proliferation of the lining membrane. In a little 
while the cancellar walls begin to lose their earthy ingredients, to become- 
soft and flexible, and then to be absorbed, getting thinner and thinner until 
throughout the area of inflammation they .form a wide-meshed reticulation 
of very attenuated bone strife ramified through the newly formed granulation- 
tissue ; or may altogether disappear, leaving throughout the district of in- 
flammation, or in the most diffuse cases throughout the bone or epiphysal end 
of the bone, a mere soft fleshy mass. More frequently it happens, before this 
phase is reached, that some portion of the inflamed tissue suppurates, ulcer- 
ates, or becomes carious ; or again, that some of it dies and is slowly sepa- 
rated from the yet living part. Of these processes— abscess, caries, and ne- 
crosis, the first must needs be in the substance of the bone ; caries, though 
generally on the surface, is sometimes in the internal parts. Hence both 
it and necrosis receive different names according to situation, which may 
be on the surface (superficial), or may involve a portion of both surface and 
deep parts (partial), may only effect deep parts (central), or the entire bone 
(total). 
i The very close resemblance between inflammation of a cancellous bone 
and the non-phlebitic osteo-myelitis of a long bone must not be overlooked. 
In this latter, the simply constructed tubular membrane is inflamed, while 
the osseous wall becomes absorbed and thin ; in the former the far more 
complicated membrane, divided and subdivided into innumerable cavities 
and partition walls, also becomes hypersemic, granulates, perhaps suppu- 
rates, and each bony wall yields to a process of more or less gradual absorp- 
tion. Histologically the action in every, even the minutest, cancellus is the 
exact counterpart of the whole ; whether simply in other such spaces, or in 
the much larger medullary cavity of the bone. 1 

If, on the other hand, we examine the fully developed disease as affect- 
ing the solid parts of bone, we find in the living subject the deeper layer 
of the periosteum swollen red and easily separated from the underlying 
surface. The membrane comes away either clean, i.e., bringing no bony 
flakes with it, or if the case be further advanced, the softened outer lay- 
ers of the bone, those consisting of concentric plates (p. 3), adhere to 
the membrane as a pultaceous mass, and leave an irregular columnar sur- 
face behind. If the bared bone be incised with a strong knife, or sharp 
chisel, it will be found to cut as readily as a piece of boxwood, the shavings, 
like those from the wood, curling up as they fall away. The fresh surface 
is pink, bleeds pretty freely, and may be seen even with the naked eye, but 

1 Clinically, the two maladies are less alike than they are histologically. But cases 
on the operating-table occasionally show that years before an osteomyelitis had, un- 
suspected, produced a condition of bone for which the patient now seeks relief — be it 
localized abscess, necrosis, or other such state ; inflammation of the medullary mem- 
brane not being always $hat diffuse and violent process which the term osteo-myelitis 
is generally taken to mean. 



216 



DISEASES OF THE JOINTS. 






# 






Bag ftjijiifiB 







ME 



Ksiftl^rt 



better with a simple lens, to be lined and spotted with bright red grooves 
and pits, from which the blood flows, and which are in fact greatly en- 
larged Haversian canals that have been cut through in different directions, 
and which contain hyperaemic Haversian vessels, besides other things to he 
immediately named. These channels and pits have been formed at the 
expense of the solid substance, they cause the bone to be porous and sieve- 
like (osteo-porosis) ; and as the re- 
maining substance, the septa be- 
tween the canals, are at their edges 
also softened, malaria may be super- 
added. 

If now these two accounts of os- 
titis occurring respectively in the 
solid and in the spongy parts of bone 
be compared, it becomes evident 
that the action is the same in both, 
namely, certain membranes, normal- 
ly present in bones, in the one case 
H&g* Jg-p lining cancellar cavities, in the other 

" Haversian canals, etc., increase and 
enlarge at the expense of the solid 
tissue, which becomes softened, dis- 
integrated, and at last absorbed. 
Portions indeed die ; if they be small 
they mix as grit with the new mem- 
branous formation and their secre- 
tion — caries: if larger, they lie as 
visible masses, or sequestra, and the 
process is termed — necrosis. If the 
new soft tltesue formed by this in- 
crease of the normal membranes be 
examined microscopically, it will be 
found to consist of cells, amongwhich 
in spongy bone are many giant cells 1 
bare nuclei, and granules traversed 
by long, slender, and fine-looped vessels. In fact, the tissue, though in cer- 
tain points it resembles foetal medulla, is simply granulation produced by 
cell-proliferation from the normal membranes of the bone. 

A point very interesting to the scientific pathologist is the mechanism 
and chemistry of the inflammatory bone absorption, which enlarges the 
Haversian canals, or the cancelli as the case may be, and thus makes room 
for the proliferation and granulation of the soft tissues. The obstacles to 
histological investigation are enormous, and will be indicated immediately; 
the difficulties, in obtaining a clear comprehension of the processes, arise 
in the fact that, when inflammation attacks any soft tissue, elasticity of the 
part allows sufficient area for hypersemia, effusion, and cell-proliferation. 
But such an amount of space is hardly procurable in a tissue so hard as 
bone ; another hindrance to a clear view of the process lies in the double 




Natural size. 



1 The presence of these cells gives the granulation-tissue a striking resemblance to 
infantile medulla ; they are always present in normal or abnormal tissues, which lie in 
contact with bone undergoing absorption, whether natural, as in change of form, or 
diseased as in myelitis. (Colli ker terms these cells osteoclasts, a term which, as it im- 
putes an unproven function to a certain organism, ought to )m rejected, lest in a few 
years we have to invest them with a new name. 



CHKONIC OSTITIS. 217 

constituency of bone, viz., cartilage and insoluble, hence in that state non- 
absorbable lime-salts. The key of the whole question lies in the explana- 
tion of one particular phenomenon, viz., the mode of formation of those 
rounded or oval excavations, so well known by the name of my predecessor 
at the Charing Cross Hospital as " Howship's lacunse." These excavations, 
sometimes seen as smooth grooves, sometimes as rounded pits lying close 
together» but separated by ridges or pyramidal projections, are seen on the 
surface of necrotic or carious bone, also at the margins of Haversian canals 
encroaching into the osseous tissue proper (see Pig. 23) — in fact on any 
normal or abnormal surface of inflamed bone. They are usually, though 
not always, filled by soft granulation-tissue ; and represent spaces from 
which the bone has disappeared by a process of solution and absorption. 
The agency productive of these effects is the point in question. 

One school of observers, Virchow, 1 Foerster, 8 Rokitansky, 3 to which 
also, in Germany, I am considered to belong/ believe or have believed, that 
the Howship's lacunse are hollowed out by changes, which take place in the 
bone -substance itself, through certain actions of the lacunar cells, To put 
the gist of the matter in the shortest possible language, it is asserted by 
Virchow 6 that bone, like other connective tissues, consists of cellular ele- 
ments and of intercellular substance (Grundsubstanz), and that each cell 
governs and maintains a certain territory of the latter material. The bound- 
aries of each government are lost or obscured during health, but in patho- 
logical conditions, such as inflammation, they reappear, by the simple fact 
that one district will become the subject of an excited and enlarged lacunar 
cell, therefore changed in certain ways or converted into a different tissue, 
for instance, into granulations ; while neighboring territories remain nor- 
mal and hard. Therefore, under this interpretation, the Howship excava- 
tions are the gaps whence certain cell-territories have, through some influ- 
ence of the bone-cell, softened and disappeared along a given surface, as 
that of a sequestrum, or on a surface of living bone, from which a dead 
portion has separated, or deeper, as in a burrowing caries. Virchow, Foers- 
ter, and I have given representations of inflamed bone with lacunse thus 
enlarged. But, be it observed, Virchow expressly states that all excava- 
tions on the surface of dead or inflamed bone are not thus produced, but 
only those which in size and shape correspond ' to the cell-territory — for 
Stanley, Erichsen, and Von Langenbeck have shown that the ivory pegs 
used to promote the healing of an ununited fracture (ivory is a structure 
without cell districts), become excavated into large and small gaps, or la- 
cunas, very like those of Howship. 

Another school of morbid histologists, among whom Billroth stands pre- 
eminent, considers that throughout the process of inflammation osseous 
tissue is merely passive, and incapable of inflammatory action. That great 
observer says : " Is there, moreover, such a thing as acute inflammation of 
osseous tissue ? If we assume as our starting-point that enlargement of 
vessels, infiltration by cell-elements and serous infiltration of the structure, 
combined in relatively various proportions, constitute the necessary condi- 
tions of acute inflammation, we must deny the possibility of such an action 
in compact, perfected osseous tissue ; for all these processes in the hard 

1 Cellular Pathologie, p. 521, fourth edition. 

2 Atlas der mikroskopischen pathologiachen Anatomie, Taf. iii. , fig. 5. 

3 Lehrbuch der pathologischen Anatomie, third edition, vol. ii. , fig. 8. 

4 Volkmann : Zur Histologic der Caries und Ostitis ; Langenbeok's Arohiv, vol. iv., p. 
443. • 

5 Loc. cit„ p. 18. 



218 DISEASES OF THE JOINTS. 

cortical substance of a long bone are not conceivable." ' He proceeds then 
to show that absorption of bone is simply effected by the granulations 
which arise from the membrane lying in Haversian canals, and which prob- 
ably secrete, as solvent of the lime-salts, lactic acid; 2 that the rounded ex- 
cavations (Howship's lacunse) receive that particular form; not from any 
action of a cell upon its territory, the existence of which he denies, but by 
simple modelling upon the rounded form of absorbing granulations^ through 
whose agency alone bone can be thus dissolved. He supports this view by 
reference to the erosion of ivory pegs, artificially introduced. The exami- 
nation of one, that he had thus used, disclosed pits, grooves, and markings, 
closely resembling Howship's lacunse. 

Volkmann occupies between these two opponents a middle place. His 
paper, above referred to ("The Histology of Caries and Ostitis") is well 
worthy of study. He has brought many new facts to light, more especially 
as to the rapid perforation of solid bone by arteriferous canals. My point 
of view has, I confess, also somewhat changed ; it is impossible to follow on 
prepaftitions, the cogent reasonings and clear descriptions of Billroth, Lie- 
berkiihn and others, without perceiving, that, in many sorts of ostitis, the 
granulation from soft parts plays a very important part, but not, I believe, 
the whole drama, for it appears to me that Billroth is far too exclusive, and 
that even his reasoning above given is open to grave exception. Why, for 
instance, must enlargement of vessels, cellular and serous infiltration, be 
regarded as essential to acute inflammation, and why are these inconceiva- 
ble in compact bone-tissue ? Cartilage, as I have elsewhere pointed out, is 
occasionally acutely inflamed, yet even in. the most intense form we find no 
vessels in the structure itself, and what cellular infiltration exists originates 
in the very cells of the tissue. Certamly, it appears to me that enlarge- 
ment of vessels is not only conceivable, but demonstrable, in hard bone-tis- 
sue (see Fig, 23). Let us also consider the first step in ostitis affecting a 
small tract, through which runs an Haversian vessel. Can this first step 
be granulation within the cajial ? — if so, there must either be room for its 
formation — therefore room for enlargement of the vessel and for serous 
effusion — or there must be no room, and the granulation, if formed at all, 
must compress the vessel and cause death of the bone. Or if granulation 
from the cells of the Haversian membrane can arise, and then by bone- 
absorption make room for itself, one fails to see why the cells of the lacunse 
should not act in the same manner. But if granulation be not the first 
step, if it be delayed until some absorption of the Haversian wall have made 
room for it, then there is some material other than granulation endowed 
with the power of absorbing bone. Moreover, it must be observed that the 
enlarged Haversian canals are at first always smooth-walled, as 'Howship 
pointed out, therefore cannot be moulded on granulation surfaces ; hence 
the enlargement is not due to such growths. The lactic acid theory, 
although very facile and plausible, rests upon the results of one very pecu- 
liar case ; for, as an almost invariable rule, the secretion of bone-granulations 
is alkaline. 

If with Billroth we totally deny the action of lacunar cells, we shall have 
to explain, not so much how ivory pegs are eroded, but rather why they are 
'so very seldom attacked. It has been my fate to use twenty-seven pegs for 
old ununited fractures, and I have seen but one (now in the Museum of 



1 Die allgemeine chirurgisohe Pathologie und Therapie, p. 416. 

2 TJeber Knocken-Resorption, Langenbeok's Arohiv, vol. ii., p. 126; Lehrmann'fl 
Physiolog. Chemie, vol. iii. , p. 26. 



CHRONIC OSTITIS. 



219 



Charing Cross Hospital) which did not come out of the granulations as 
smooth as it went in. Is not the erosion therefore indicative of some pe- 
culiarity in the sample of ivory ? Again, why should dead bone resting 
upon granulations be so much more slowly absorbed than living bone — so 
slowly, indeed, that although the minute anatomist may be able to find here 
and there the traces of rodent action, yet for the practical surgeon, seques- 
tra are, to all intents and purposes, incapable of absorption. While live 
bone — and life should preserve against influences from without — is fre- 
quently largely dissolved, therefore such solution is more or less a vital act, 
not a mere passive yielding. 

Although I controvert the views of such a man as Billroth with very 
great diffidence, yet I cannot but think that he has been somewhat .misled 
by two circumstances— by his view of the constitution of bone and by his 
method of investigation. He appears to me to separate, in a manner far too 
trenchant, the membranous and the osseous constituence of bone, to .con- 
ceive bone as consisting of separate and isolated islands of solid tissue, di- 
vided from each other by channels (Haversian), containing vessels and cel- 
lular tissue, which have nothing to do with the bony parts, save to convey 
nutriment to them. I cannot look upon bone in this wise ; as elsewhere 
stated (Chapter I., p. 3) I consider the Haversian lining membrane to be 
continuous with the lacuna? and canaliculi ; that this branched structure is 
the unossifled portion of a tissue, the other portions of which have re- 
ceived a deposit of lime-salts ; that this non-calcified part of the bone, al- 
though it takes no part in the mechanical, the resisting and supporting 
function of the skeleton, is an essential 
constituent of bone as a living, grow- 
ing, and self-nourishing part of the 
body. Could we destroy all this in- 
tricate mesh of cells and fibres the 
bone would be dead in a few minutes. 
Could we remove all the other, all the 
hard part without damaging this net- 
work, the bone would soon be recon- 
stituted. Nor can I conceive that one 
little portion of the system— that, 
namely, which lines the Haversian ca- 
nals, could be inflamed without ex- 
tension of the action to other parts, 
those within the canaliculi and the la- 
cuna? included. 

tj. * j. -i i i-i __ ■ i Fig. 24. — Section of the femur of a rabbit — nor- 

It IS true that the microscopical mal— magnified 500 diameters. 

verification of inflammatory acts with- 
in these minflte channels and-rifts is much more difficult than in the larger 
canals ; and herein lies, I think, the second cause of Billroth's too exclusive 
reading of the subject. His method appears to be only one, viz., dissolving 
out the lime-salts of the bone to be examined, a method which entirely ob- 
scures, indeed generally destroys, the appearance of lacunae and canaliculi, 
as well as certain peculiarities in the substance itself. All histologists have 
acknowledged the many difficulties encountered by those who extend their 
researches into the morbid appearances of osseous tissue. I believe that 
the truth can only be reached by multiplying for each specimen the modes 
of observati6n, both rubbing down the entire tissue, and by making decalci- 
fied sections ; even as I have done, first grinding the bone thin and making 
a careful drawing, and then decalcifying. I hope in another place to give 




220 



DISEASES OP THE JOINTS. 




",1»W.W» 



Fig. 25. — Section fcf femur of a rabbit, close to fracture, mag- 
nified 500 diameters. The lacunae may be seen large and round. 



the result of much laborious study on this subject ; but this work, more 
especially intended to be clinical, hardly affords space for more than the 

mere gist and outcome of my 
investigations. 

In whatever actions a bone 
or segment of bone, whether 
solid or cancellous, is in- 
volved, the Whole mass, the 
soft parts and the hard parts, 
are inseparably conjoined. In 
the first edition of this work, 
certain conditions resulting 
from experimental fracture of 
the bones of rabbits were de- 
picted which show, as a con- 
sequence of the inflammatory 
condition thus produced, con- 
siderable enlargement of the 
lacunae (Figs. 24 and 25). I 
have the preparation still, and 
the figure is true to nature, 
but it is very rare to find in 
the solid bone-tissue of the 
human subject such uniform 
and general enlargement. Yet since the above lines were written I have had 
the opportunity of studying a portion of human femur which is very instruc- 
tive. The bone is that of a child aged three, who had acute necrosis of the 
tibia, and suppuration of the knee-joint ; the inflammation was spreading 
up the thigh, which was amputated below the 
middle. The femur was in an early stage 
■of acute inflammation, it was red but still 
hard, sections showed the Haversian canals, 
not at all or very slightly enlarged, stuffed 
with cells, leucocytes, and granules. The 
lacunse were, some of them, of normal size, 
but most of them enlarged one-half ; they 
were crowded with oil-globules, nuclei, and 
granules. Other specimens (of which I have 
a great quantity) taken from bone in the 
condition depicted in Pig. 23, show in trans- 
verse section, at, the margin of the enlarged 
Haversian canal, many of the lacunse, either 
not increased or but very slightly so ; yet, if 
the part be carefully cleaned, the contents 
under a high power will be found to consist 
of a number of cells and nuclei, or (according 
to the mode of cleansing adopted) of oil- 

globules: A longitudinal section shows la- T^lnl^ZTZ^n^^t 
cunar enlargement far more clearly; it seems circular portion at tar side represents the 

41,n* +U„ -™„„„ t i • i ■ • edge of a cancellus. The longest lacuna is 

that the pressure of concentric laminae lm- ^ Une in i engtti; the IargeBt ova i has a 

pedes increase in one direction, but offers long diameter of -rio-iine. 

less resistance in the other. Again, if a thin 

plate be taken out of an inflamed cancellar bone, enlarged lacunse are 

found filled with the above-described contents, but in this situation more 



lit- : IIP 


h-. 


111 - < £*d 

Mm *m 


M 




A 



Fig. 



-Represents a lamina taken 






CHEONIC OSTITIS. 



221 




Fig. 27.— Represents a lamina takes 
out of the spongy portion of the upper end 
of a human tibia in a carious condition. 



especially with oil-globules (Figs. 26 and 27). Very remarkable is a form 
of strumous ostitis of cancellar bones, very common with children in which 
the development of fat is enormous ; the whole tissue, cells, membranous 
parts, and even the solid bone, is bathed and soaked in oily matter, and in 
such cases the rapid softening of tissue is very prominent. From this 
condition, as well as from the fact that the 
medulla plays an important part in the ab- 
sorption and modelling of bone, I would con- 
clude that some fatty and not the lactic acid 
is the solvent of osseous lime-salts. 

As for the appearance of the solid tissue 
itself under the influence of rarefying ostitis, 
I can only say, that sometimes it is granular 
or granulated, that is, marked out by slightly 
deeper gray coloration, surrounding clearer 
spaces, into an appearance I can only de- 
scribe by imagining the scaly side of a fish 
greatly diminished. Sometimes this darker 
coloration occurs in wavy striae — sometimes 
the whole has an almost uniform yellowish 
tinge, is more opaque (if examined in fluid) 
than normal, with here and there a blotch 
of gray, finely granular consistence. As far 
as my investigations have as yet gone, I 
should say that the first described appear- 
ance Corresponds to a Slow, gradual Soften- The upper portion of theTuTshowTamere 

ing-the strise, which usually run longitudi- g^TZiSSM'S^bkh aSf cSS 
nally, i.e., in a line with the Haversian canals, from the bone are scattered. intheiacun» 

j i . -, ,. -i -t it Ti many nucleated cells are frequently to be 

denote a more rapid action, While the yellow- seen ; one, in the lower rigljt corner, is con- 

ish discoloration appears to occur in speci- s P icU0US *? r '. it8 ?™. *»* appearance ; it 

.... -I*-, t. r . measures -gSr line in diameter. 

mens that nave been on the verge of necrosis. • 

Eecapitdlation. — An immense space of investigation and of controversy 
has been gone over in the last few pages, and lest I should leave the mat- 
ter more obscure than I should wish to do, I propose to condense in a few 
sentences the real histology of ostitis. 

The periosteum and endosteum of bone are in communication with 

each other through the inter- 
vention of a fine web, consist- 
ing of cells and fibres, which 
permeate the whole space be- 
tween these membranes, after 
the manner of the yellow 
areolar tissue. In this web 
vessels ramify in intervals 
much wider than the mesh- 
work of the web itself. This 
web consists of Haversian li- 
ning membrane, lacunar cells, 
and canalicular fibres. The 
interspaces are filled up by an 
intercellular material, partly 
cartilage, partly lime-salts. "When a district of bone inflames, the areolar ele- 
ments are the active agents, and proliferation takes place in all cells through- 
out the district, whether these cells_are placed in the Haversian, cancellar, 




Flo. 28.— Upper surface of tibia, caries from ostitis. 



222 DISEASES OF THE JOINTS. 

or lacunar lining, in the periosteum or endosteum. The proliferation is 
easiest to demonstrate in the largest spaces, i.e., in the outer or inner mem- 
brane most easy ; in the Haversian lining less so ; in the lacunar portions 
very difficult. On account of this proliferation, much of the previously 
normal cellular elements are converted into granulation-tissue, assimilat- 
ing, or, in other words, converting into their own substance the intercellu- 
lar parts of the structure, i.e., their chondrin. The lime of those parts 
falls away, partly in mere detritus (holding no chondrin at all), but is also 
partly dissolved and carried into the venous circulation. The solvent of 
the lime-salts is in all probability one of the fatty acids. In the case of can- 
cellar bone, the parts which are played by the membrane lining the Ha- 
versian canals and by the endosteum is assumed and carried out by the 
membrane lining the cancelli. Hence, as such membranous parts and the 
vessels are much more abundant, so do we find all actions more rapid and 
■widespread ; a bone at such parts is not uhfrequently eaten into pits and 
hollows, deeply and profoundly excavated. Contrast Kg. 27 with Fig. 23, 
ostitis of solid bone, and with Fig. 28, which is the sort of caries found on 
cancellar bone-ends. 

Osteo-sclerosis, a somewhat different form of inflammation, is, as the 
name implies, characterized not by softening or rarefaction of the bone ; 
but by increased hardness and density of the tissue. Ostitis arising from 
certain constitutional cachexise tend more especially to condensation ; such 
are the rheumatic, certain forms of syphilitic, and, in some phases of the dis- 
ease, arthritic inflammation. Induration also generally surrounds portions 
of bone which are undergoing the softening form of inflammation (unless 
it be of the more diffuse form), and indeed often precedes this condition ; or, 
when the disease changes and tends to resolution, follows it andf orms the 
second step in the process of repair.- Up to a certain point, then, the histo- 
logical processes, though slower in the condensing variety, are the same 
in both forms of inflammation. The same, that is to say, up to the time 
when granulation has formed, when in a district of solid bone, the Haver- 
sian canals have been enlarged, but are still smooth-walled, are not hollowed 
into Howship's lacunae, and solution of lime-salts has not begun. 

And now the newly-formed material, instead of going through retro- 
grade processes, commences formative action, changing into one of the 
many sorts of fibrous tissue, 1 which subsequently becomes ossified certainly 
on the Haversian walls, and probably too on those of the lacunse. On this 
latter point I will not speak positively, as the investigation is very difficult. 
But I may point out as certain that in all indurated parts of bone the canal- 
iculi are more strongly marked than in the normal tissue, and that they ap- 
pear more crowded and more numerous. This arises not from the forma- 
tion of fresh channels, but from increase in refraction of the bony tissue in 
consequence of the additional lime-salts deposited interstitially giving to 
the light-beam a more acute angle. To the naked eye, bone thus affected 
shows a greater whiteness and opacity, as also greater hardness and greater 
weight. Under the microscope the Haversian canals appear smaller, the 
lacunse and canaliculi more clear and distinct — in some specimens the sub- 
stance itself is marked by delicate fines, as of large granules or as the de- 
limitation of crystals ; it is moreover very opaque and difficult to manage ; 
sections when becoming thin enough are apt to fall to pieces, into mere de- 
tritus. 

1 For the differences between formative and destructive termination to granulation, 
see Chapter V., p. 97. 



;M 



CHRONIC OSTITIS. 223 

• 

The induration of cancellar portions, which very seldom amounts to 
more than consolidation, is much more easily understood ; it is simply the 
same process, which takes place when any new layer of bone is formed from 
either periosteum or endosteum, only the deposition goes on from every 
subdivision of membrane and upon every cancellar wall, until each cavity 
is either quite obliterated or until only space enough is left for its vessel. 
In either place, whether in solid or cancellar bone, the destructive act, end- 
ing in softening caries, etc., is the result of an irritation larger than power ;— 
the indurating act the effect of a less irritation or of greater power. Hence, 
in cancellar bone the focus of irritation, be it a merely softening portion or 
an abscess, is surrounded by a hardened ring ; some part of this may sub- 
sequently soften to allow a passage of pus outward, or if the inflammation 
(merely a malacia) decline, induration will succeed to the softening in the 
centre of disease, while in the circumference, the hardened portion will be 
restored by reabsorption of the newly deposited bone. 

. The effects of granulating or proliferating cells within the hard portibns 
of bone-tissue are thus seen to vary with the more or less sthenic form of 
inflammation, that is to say with the further development of the granulation 
itself. At present we have but considered the indurating and the softening 
process, but there, are still other conditions which modify the fate of the 
part. Thus, in very cachectic states, large districts of the new cell-growth 
may fall into fatty degeneration ; and not only itself perish, but cause the 
death, the necrosis of all the enclosed bone. Again, tubercle may be deposi- 
ted in the granulations, thus greatly prolonging and extending both the 
duration and area of disease. 1 

Thus, when in a cancellous bone-end, for example the head of the tibia, 
inflammation has occurred, one or more of the following events may be ex- 
pected, resolution, osteo-sclerosis, osteo-malacia, abscess, caries, necrosis 
(the last three may be combined with tubercle). The proximate effect, if 
any, upon the joint, will in great measure depend upon the situation of the 
disease, whether or no it be near or far from the surface, forming part 
of the articulation, and whether it tend to advance in that or in some other 
direction. 

The condition in early childhood of epiphysal ends or of short bones, 
produces certain, by no means unimportant, varieties in the course of in- 
flammation. The solid bony nucleus of these parts surrounded by a case 
of cartilage more or less thick according to age (see p. 5) and the peculiari- 
ties of its nutrition, modify morbid actions in various ways. In studying 
these conditions, although we may without difficulty obtain specimens of 
advanced disease, yet in the ordinary course of surgical treatment, it is 
manifestly impossible to procure examples of the primarily affected joint- 
ends during early malady. I have, therefore, availed myself of the follow- 
ing sources : 

A In one case the femur and in one the tibia, in another the humerus 
affected with early primary ostitis, the patient having died of some other 

1 1 have often expressed the opinion that there is no such thing as tubercle of bone, 
and I am by further study confirmed in this view, since I have never seen gray tuber- 
cle in osseous tissue proper, although I have several times seen tubercle-like masses, 
and once true gray tubercle among granulations, but more often still have observed 
little round lumps of inspissated pus, closely simulating tuberculous deposit. At first 
sight it may appear mere hair-splitting to say that tubercle is not to be found in bone, 
but in the osseous granulations ; a little further thought will show that the distinction 
is essential, since ra the one it would be the cause of, in the other the consequence of 
morbid action. 



224 DISEASES OE THE JOINTS. 

strumous malady (phthisis, tubercular peritonitis and meningitis respec- 
tively), which in the two first cases preceded the joint disease. 

B. The other hone of any large joint to which the inflammation had 
spread from the epiphysis primarily affected, or from a pre-existent syno- 
vitis. 

C. Bones of the carpus and tarsus commencing to be secondarily 
affected. • 

In giving the results of these investigations, I must premise that some- 
what different forms of inflammation, especially with regard to diffuseness 
over the whole or limitation to a part of the epiphysis, present themselves. 
Secondary affections are either diffuse or only a little more marked on the 
side next the original malady, while diffuse primary ostitis is always com- 
bined or produced by some strongly marked cachexia, more especially by 
the strumous. 

The local conditions commencing with the earlier appearances are as 
follows : 

1. Hypersemia giving a more or less deep red color to the bony nucleus, 
throughout or limited to a part (the color of the nucleus while still solid or 
nearly so, is yellow or but very slightly pink). 

2. The same with effusion of serum, sometimes blood-stained, that lies 
chiefly between the cartilage and bone over a space more or less large. 
The cartilage at that spot has either become blood-stained, vascular, or both. 
(If the age of the patient be such that the bony nucleus is already chan- 
nelled into cancellous-like cavities, the fluid effusion occupies also those in 
the neighborhood.) 

3. Pus or pus and blood-stained serum in the same positions as above 
described. 

4 A peculiar gray discoloration with softening of the bone nucleus ; 
this may occur in a spot near the circumference or near the centre, and may 
occupy but a small portion, or nearly all of the nucleus. 

5. A carious cavity occupying more or less of the nucleus, adjacent to 
which the cartilage is also ulcerated and fibrous — the cavity contains thick 
creamy pus— after a time more and more of the cartilage, toward the near- 
est surface becomes absorbed until an external opening gives exit to the 
pus among the soft parts. 

6. Necrosis of the entire nucleus, which may shell out of the cartilage 
like a kernel from a nut. In such cases the dead bone is always entirely 
surrounded by thick creamy pus. 1 

These conditions may be verified by collating the appearances in such 
specimens as I have named above, and I believe that they are here reduced 
to their proper order. Accompanying the changes within the epiphyses 
are certain conditions of the surrounding soft parts all reducible to inflam- 
matory action, viz., very considerable thickening and induration (often 
called solid oedema) followed by deep suppuration, sometimes confined to 
the immediate vicinity, in other cases widespread (adjacent and neighbor- 
ing). As a rule the abscesses thus formed do not communicate with the 
pus inside the epiphysis until a late period of the disease. 

Greatly as I have tried to condense the histology of ostitis, yet its de- 
scription has greatly exceeded the intended limits, especially as there still 
remains the subject of our chief interest, the relationship between bone- 



1 1 believe, but the 1 matter cannot be proved, that the pus formed rapidly in one 
part only of the structure and not able quickly to escape, produces the total death ot 
the bone-nucleus by becoming effused between it and the cartilage. 



:*M 



CHRONIC OSTITIS. 225 

inflammation and joint disease. This is modified by various circumstances, 
the most important being the stage of development of the bone itself — for 
the entire independence, nutritive and otherwise, of an ununited epiphysis, 
as also the more or less maturity of the bony nucleus modifies the form and 
progress of disease. The part of the bone affected, whether, namely, the 
inflamed spot be near the joint, near the external surface, or near the epi- 
physal line, makes a great difference in the form and prognosis of the mal- 
ady. In case the inflammation be near the epiphysal junction, the in- or 
exclusion thereof, from the joint-cavity, is a very important factor in the- 
subsequent events. The species of inflammation has also a marked effect 
in .determining the result. Those inflammations, as are rare in infantile 
life, which do not tend to suppuration, are less injurious at an epiphysis 
than those of pus-producing quality, such as struma or syphilis. Trau- 
matism takes a place with one or the other, according to its severity and 
according to the patient's constitution, whether, namely, it be sthenic, or 
cachectic and strumous. It will, of course, be remembered, that many stru- 
mous inflammations are in the first instance lit up by an injury. 

The frequency of strumous epiphysitis in the young subject is to be ac- 
counted for in part by the greater prevalence of all manifestations of this 
cachexia in the young ; ajso, and in larger part, by the hypereemia and hy- 
perplasia (a necessity of growth in stature) which occupy the epiphysal bone- 
ends and supply that increment of slight irritation, responded to by pro- 
longed inflammation, on which Billroth bases his definition of struma. In 
the infant, while the bony nucleus only partially fills the joint-end, certain 
peculiarities, already particularly described, obtain. In the rather older 
subject the proximity to, or distance from the articular surface of the in- 
flamed spot, influences not merely the rapidity, but also the mode of joint 
implication. 

If the inflamed or suppurating point lie nearer to the external than to 
the articular surface, the bone-end attains a considerable size, even perios- 
teal abscess may form while joint-affection (synovial fulness and thicken- 
ing) is as yet hardly demonstrable. Such cases afford the easiest ground- 
work of diagnosis, the bone-inflammation spreads by way of the periosteum 
very gradually ; the symptoms of fungating synovitis, i.e., gradual soft thick- 
ening of the synovial membrane, are not preceded by fluid effusion into the 
cavity. 

An inflammation, situated near the articular surface, or spreading to- 
ward it from the central parts of the, epiphysis, implicates the joint soqner 
and in a peculiar manner ; for when the malady reaches the sub-articular 
cancelli, the cartilage and subjacent lamella become detached in spots ; or 
if the disease be extensive on a large part of its surface (see Fig. 47) a 
breach either by laceration or necrosis occurs, inflammatory products distil 
into the joint, and a synovitis commencing with fluid effusion results — sy- 
novial thickening then subsequently arises. 

Should the inflammation be close to the epiphysal line, and track along 
it outward, the joint may escape, or more probably will be slowly implica- 
ted, after the first method if the junction-line lie outside the synovial sac ; 
but if the epiphysal line be included within that membrane, the articula- 
tion will become involved, probably severely after the second method. (See 
Hip Disease.) 

Infantile epiphysitis has been described, and different appearances ac- 
cording to the phase of the disease indicated. The earlier two are, judging 
chiefly from symptoms, not uncommon, and often get well with no or but 
very slight involvement of the joint ; the last four are exceedingly grave. 



226 DISEASES OF THE JOINTS. 

Pus formed within an ossifying cartilage will make exit somewhere, and if 
toward the joint severe disease will arise. The malady is sometimes sim- 
ply acute suppuration — if the synovial membrane have been previously 
healthy or nearly so — if that structure have been previously granulating it 
has become less sensitive, the contact of pus produces a subacute disease ; 
or, if the joint be already inflamed by continuity, the eruption of pus hardly 
aggravates the condition. 

After death or amputation various states are found, according to the 
sort of primary disease indicated at p. 223. They are these : a nuclear ab- 
scess opening into the joint. 1 Abscess on the epiphysal line opening into the 
joint (acute joint disease), or away from the joint (chronic disease). Almost 
entire disappearance of epiphysal end (this corresponds to 5 and 6 of my 
description), the bare diaphysis lying rough, and carious in a large articu- 
lar abscess. Shrivelling and puckering of the epiphysal end with small 
pulverulent nucleus ; generally a joint-abscess opening in one or in several 
directions. 

In both the infantile and the later form of ostitis peri-articular and ad- 
jacent abscesses are common : the latter, more especially when the primary 
malady is caries, has a great tendency to steal along the bone, sometimes 
even to a great distance from the joint. Again, long intra-osseouistebscesses 
are by no means uncommon. They are discovered during excisions, and 
represent on the sawn surface a mere circlet of softening, which on further 
investigation is found to be the section across a more or less narrow sinus, 
running up or down the bone beyond the epiphysal line into the shaft, even 
into the medullary cavity. The other end of the sinus that in the epiphy- 
sis itself usually ends in a larger abscess, which may or not, by destruction 
of cartilage, communicate with the joint-cavity. In such cases it is evident 
that an epiphysal abscess, beginning probably about the nucleus, passed in 
two directions to and from the articulation. 2 

Symptoms. — "We have seen that strumous inflammation of the joint-end 
of a long bone is rare in the adult, and common in the young subject. 
Hence, when a grown person is found affected with ostitis in such a part, it 
is generally traceable to some other cause — rheumatism, syphilis, or injury. 
Yet it occasionally happens that such disease does occur in grown persons ; 
but then it is more rapid, and ends rather in necrosis than in caries, and is 
almost confined to the head of the tibia ; though it does occasionally at- 
tack the femoral condyles. A scrofulous inflammation of bone is among 
adults more common in the short, irregular, spongy bones of the carpus or 
tarsus, but in children nothing is more common than inflammation of the 
epiphysal ends of the bones. 

The first sign of an ostitis commencing as a chronic disease is a dull 
aching pain in the part, generally increasing at night. "When it occurs at 
so early an age that the patient is not able to give an account of his suffer- 
ings, the nurse or mother will first observe that the child is restless at night 
and cries when, during washing or dressing, the affected limb is moved. 
"When once attention has been thus directed to the part, it will very soon 
be found that the child avoids using that limb as much as possible. Such 
symptoms, when they have for a day or two been sufficiently constant to be 
undoubted, should never be neglected, but the sufferer should be subjected 

1 See Cases 59, 60, 61, and Mr. Brown's case in Clinical Society's Transactions, vol. 
ix., p. 175. 

2 Such a find always causes one to reflect upon the possibility (supposing one had 
been able to diagnose such abscess) of forestalling implication of the joint. 



CHRONIC OSTITIS. 227 

to skilled examination.' The child's nurse or mother will point out to the 
•surgeon which limb or which joint appears to her the one affected, and the 
movements which cause crying or flinching. He should then examine those 
movements, joint by joint, so moving different parts of the limb that only 
-one joint is stirred at a time, and thus, by watching the expression of face, 
he will soon know in which the pain is situated. At this early stage the eye 
will scarcely be able to detect any difference between the affected limb and 
its fellow. He should then subject the part to a careful manipulation, and 
should accurately compare the shape and size of every point of the bones 
forming the joint with those of the fellow limb : thus no alteration can es- 
cape him. The first intimation of change is not so much actual swelling ; 
■we have seen that the bone itself very rarely enlarges, or, as has been sup- 
posed, becomes distended, as by some internal force. What little swelling 
there may be affects the periosteum and the fibrous textures immediately 
around. It is at first but slight ; I have seen many cases of early ostitis, in 
which accurate measurement, by a tightly drawn band, has shown no swell- 
ing ; but in which examination by the hand could detect a subtle change 
in form, consisting in greater breadth of all the elevations and less depth 
of all the natural depressions of the part. It sometimes happens that one 
particular spot will more markedly project, and here a sense of fluctuation 
often false, may be detected ; such condition is accompanied, if the bone be 
quite superficial, by increased warmth, generally also by tenderness. Such 
symptoms, corresponding to the changes described as appertaining to the 
first or congestive stage of the disease, may last for weeks, even for months, 
and may then subside, or indeed be altogether subdued. 

The next phase, that of true inflammation with tissue-changes, manifests 
itself somewhat differently in the earlier years of life, when the bone or the 
epiphysis is in great measure cartilaginous, and in later life when the organ 
is more fully formed. We will give this latter condition the preference. 
In this stage the heat of the part will be more marked and the swelling 
more perceptible ; the form of the joint-end of the bone will alter, or, to 
speak more correctly, the periosteum and the fibrous tissues in its imme- 
diate neighborhood will become inflamed and swollen. The tumefaction 
"will concentrate itself more particularly at certain spots, in which the effects 
of the disease will be most strongly marked ; thus the internal condyle of 
the femur will often project very much and pointedly ; the enlargement is 
not bony, but is, although hard, elastic ; swelling is, in fact, produced by 
effusion or the formation of granulations beneath the periosteum in the 
same way as nodes are caused, but over a larger surface ; the tightness with 
which the material is bound in between the tough fibrous membrane and 
the bone producing the hardness. These spots of effusion do not last long, 
but become dispersed and merged into a general diffused swelling, which 
goes on increasing until it greatly alters the anatomical forms of the bones, 
exaggerating the breadth of their processes and filling up their depressions, 
and yielding in points a sense of obscure fluctuation. This swelling does 
not spread over all the joint, but is confined to one of the bones that enters 
into its formation, indeed, often to a particular part of that bone. But, and 
this point' is, d&ough its causality be obscure, well worthy of remark, it 
often happens in large joints, more especially at the knee, when only one 

1 The reader will remember that in strumous synovitis occurring in children, swell- 
fag is frequently observed before any symptoms of pain are perceptible ; or that, at 
least, when attention has been drawn to the part by signs of pain, swelling is at once 
perceived. 



228 



DISEASES OP THE JOINTS. 



portion of a constituent bone is affected that the corresponding part of the 
opposing bone becomes involved, while the rest of the primarily affected 
epiphyses remains normal ; for instance, when the inner femoral condyle 
has been for some time swollen, the internal tuberosity of the tibia en- 
larges, while still the outer condyle remains of its natural size. This 
form of osseous swelling is often in deep joints imperceptible to the eye, 
or, at least, is too subtle to be represented by the engraver, but in su- 




Fig. 29. — Articular ostitis (internal condyle). 

perficial joints is quite evident. The subjoined plates, from photographs, 
show the enlargement of the inner femoral condyle, a frequent seat of 
ostitis, as also the absence of any other tumefaction, and a disease of the 
ankle commencing on the astragalus. The form of disease was diagnosed 
during life, and was verified by anatomical examination. To the touch, 

the osseous swelling marks itself out 
,,,>,, ...i,.. strongly from synovial thickening ; the 

former gives a sense of increased size of 
the bone covered by thin skin, or at most 
as though covered under the skin by a 
piece of wash-leather. The latter imparts 
the idea of concealed or diminished bones 
muffled by some thick, doughy material, 
which can by deep pressure be moved 
over them. Beneath this the prominences g 
and hollows of the bone are found to be 
unaltered. 

At this period it not unfrequently 
happens that the integuments over the 
inflamed bone assume, before any joint- 
malady can be detected, or before it be- 
comes accentuated, a light pink hue. The 
coloration is at first transitory, coming 
and going at uncertain periods, and with- 
out assignable cause. In some cases a 
deeper tint will follow and remain more 
constant. Until the joint is deeply implicated the skin is never abnormally 
white. This localized redness, more especially if it coincide with projection, 
tenderness or increased swelling at that particular spot, and if the pain be 
acute, throbbing, and with irregular intermissions, is usually indicative of 
osseous abscess. This probability is increased if the tumefaction be over a 
part of the epiphysal line. At about this stage of the bone-affection, 
whether or no the synovial tissues have become implicated, contraction of 




Fia. 30.— Ostitis of astragalus. 



CHRONIC OSTITIS. 229 

the flexor muscles may commence. The exact relationship in regard to 
time of this symptom is variable,' depending as it does upon the diffused or 
circumscribed character of the inflammation, and in the latter case upon its 
situation near to, or at a distance from, the articular facet. Yet although 
this retraction may, and often does, show itself before the joint itself ia 
perceptibly involved, it may, should the inflammation be near the epiphysal 
line, postpone its advent a little further. It always, however, conies on, 
very frequently accompanied by starting-pains, earlier in the malady of thb 
joint itself than in the pure synovitic disease. Very generally we find, if 
the patient be old enough to explain his sensations, that these retractions 
and startings are accompanied by peculiar vague aching along the track of 
the bone, and not unfrequently in one or other of the nervous trunks, thus 
closely simulating neuralgia. 

These startings are like those observable in the advanced condition of 
synovitis, when the cartilages are ulcerated nearly through, and the bone- 
cancelli immediately underlying the joint are injected ; but they are more 
violent, and as the bone is in these cases primarily affected, such spasms 
commence earlier in regard to the phase of the joint disease. Such violence 
and early occurrence of these pains are almost enough to mark the malady 
as an inflammation of the epiphysal end of the bone ; and they show, as 
stated in the first division of this chapter, that the osseous structure just 
beneath the articular lamella is hyperaemie, and, when very violent, that it 
is probably suppurating. But the surgeon must be careful in assuring him- 
self that he has really to do with this symptom, for when the disease occurs 
in young children he may often be misled. The ordinary heavy pain of a 
commencing ostitis increases, as we know, at night when the patient gets 
warm in bed, and the generally garbled and exaggerated report of the 
nurse will lead the surgeon to suppose the child's crying more violent than 
that dull pain usually produces. If he once stand for a few minutes by the 
bedside of a patient at night when the startings come on, he will not readily 
forget the sort of movements and restlessness they produce. The patient 
will probably be found lying in the position which the splint enforces, breath- 
ing quietly but rather quickly : suddenly he starts, perhaps half round, 
perhaps into a sitting posture, with a very sharp, peculiar cry of pain, but 
almost before he can be asked a question he lies down and goes to sleep 
again. Dr. Bauer says that, if the patient be awakened, he hardly remem- 
bers the attack of pain at all ; ' but this is doubtful, when we know that he 
remembers it in the morning ; and I have found that a child with this dis- 
ease always cried very much on waking and was frightened, and could only 
with difficulty be got to sleep again. One could not plainly make out 
whether he knew of the pain, or whether it merely made part of a frightful 
dream of which our waking him was the dreadful climax. Older people, 
from seven upwards, have the very clear idea of the pain ; but on watching 
a boy, aged ten, thus suffering, I found that he did not wake sufficiently to 
be conscious of external objects, and went to sleep again directly ; on ques- 
tioning him the next day, however, he described exactly the sort of rapid 
shock of pain which the expression of face and gesture indicated. We 
shall have occasion to recur to this symptom, as it is most important in its 
effects as well as in its semeiology. 

At this point a tabular view of the differences at this stage between an 
ostitis and synovitis will probably help the reader to follow the points of 
diagnosis. 

1 Bauer on Hip Disease, p. 8. 



230 



DISEASES, OP THE JOINTS. 



Diagnosis between Strumous Articular Ostitis and Strumous Synovitis 
in the Earlier Stages. 



Strumous Articular Ostitis. 

The first symptom is heavy, dull pain, 
with limping or other imperfection in the 
use of the limb ; this comes on before any 
swelling is perceptible. 

The pain is generally increased in bed, 
and is subject to variations ; sometimes 
quite disappearing for a time, and again 
returning. 

The sweLing at first is confined to one 
bone of the joint, for instance, at the 
Sfenee, the upper, when the femur, the 
lower when the tibia is affected. After- 
ward, though the whole joint is enlarged, 
the tumefaction is more marked, harder 
and larger over the bone primarily affected, 
and is nearly always on one side of the 
joint. The division between the constit- 
uent bones remains evident to the touch. 

In all but the deepest-placed bones the 
integuments over them are sensibly hotter. 

Retraction of muscles, often without 
any starting-pains, is an early symptom. 



Strumous Synovitis. 

The swelling is either before pain, or is 
discovered with the pain. 



Pain is a later symptom as regards visi- 
ble swelling, yet when it comes on is con- 
stant. 



The bones forming the articulation are 
blended by the swelling into one rounded, 
shapeless mass, which overlies both parts 
of the joint equally, and conceals greatly 
or altogether the line of junction between 
the two bones. There is no preference of 
place; the swelling is equable over the 
whole joint. 



The integuments are not at all, or 
scarcely, increased in temperature. 

Retraction of muscles, accompanied or 
preceded by starting-pains, is a later 
symptom. 



Such is in brief the history of a strumous articular ostitis of the joint- 
end of a long bone ending in caries or central abscess. Osseous disease is 
proverbially slow ; but this form is of all perhaps the slowest, whose steps 
are least marked and definite, subject to repeated retrogressions, followed 
by exacerbations. Its beginning, too, is often- so gradual and insidious, 
that the moment of commencement cannot be fixed ; but occasionally a 
more definite origin in some slight twist or blow will give occasion to a 
malady whose first steps are more rapid and well-marked. A more severe 
injury may indeed give rise to an epiphysitis, leading pretty quickly to sup- 
puration, which, if it track toward the joint, occasions malady so acute as 
to exclude it from the present chapter (seep. 179 et seq.); or the same 
events may after a time suddenly supervene upon a malady hitherto chronic, 
if abscess around an epiphysal nucleus open with some rapidity into a joint- 
cavity (see Chap. X.). It becomes desirable, therefore, whenever it is pos- 
sible, to diagnose intra-osseous inflammation as early as it is feasible' to do 
so ; this will exercise all the acumen which the surgeon can command. The 
signs of an abscess in a cancellous bone are little else than the symptoms 
of tension, of which, if the pus have formed slowly, but little may be pres- 
ent. Yet an- abscess not of the most chronic sort, marked perhaps by 
throbbing, by more severe pain, by aching of a sharper character than the 
dull sensation of a chronic non-suppurative synovitis, is generally present 
during some part, usually more than one part, of the twenty-four hours. 
The skin often, too, assumes in one spot a red blush, which may vanish 
and recur at uncertain intervals. Later, unless the pus-formation have 



CHRONIC OSTITIS. 231 

been very slow indeed, a tender prominence at one or the other part, and 
usually where the skin has previously shown the red signal, appears. 

In the slower forms of disease the synovial membrane becomes very 
gradually involved by extension of the inflammation from the periosteum 
to the subsynovial tissue. At first no perceptible increase of secretion takes 
place into the sac of the joint ; but a process of soft thickening commences, 
which, produced by the same granulating process as in a strumous syno- 
vitis, causes a similar condition of the part. The joint, however, does not 
become rounded and shapeless to the same degree as in the fungoid and 
pulpy granulation of synovial membrane ; on the contrary, the place of ori- 
gin of the disease maintains its pre-eminence, and is not, till late in the 
disease, so covered but that its morbid condition is to be detected by deep 
palpation exercised with some considerable pressure. The sense to the 
hand is that of an enlarged bone, separated from the skin by a more or less 
soft and not considerable thickening. In strumous synovitis the shape of 
the bones is almost or entirely obscured by a thick, soft mass, which so 
covers them that they can hardly be felt. Throughout the first stage this 
difference persists. 

There is, however, another form of disease which also may be situated 
in the epiphysal ends of bones, rather more rapid in its course, whose in- 
flammatory action terminates in a necrosis instead of in a caries. Such 
cases occur, as a rule, to persons of riper years : the first symptoms brought 
on by accident or exposure to cold are sufficiently sharp to be remarked, 
and are sometimes very severe ; perhaps there will be a shivering fit fol- 
lowed by considerable fever, and very acute pain in the bone. Gradually 
the feverish symptoms diminish, and even the pain will be less severe ; but 
it recurs with considerable violence at night, and the affected head of the 
bone swells to a marked extent. The tumefaction is hard, inelastic, bony 
— is, in fact, bone rapidly formed beneath the periosteum — the swelling 
is not covered by thickened soft parts ; on the contrary, these latter become 
thinner, and are tightly stretched. The disease (necrosis) is more common 
in the shafts than in the joint-ends of bone ; but, occurring in this latter, 
it is almost confined to the head of the tibia, olecranon process of the ulna, 
condyles of the femur and humerus. Being thus situated in parts very 
superficial, the form, shape, and consistence of the swelling are plainly ap- 
parent ; the soft parts are, as said above, stretched tightly over it, being 
more adherent than usual to the subjacent hard tissue. The pain, viz., 
severe aching, with which the disease began, soon considerably diminishes, 
and generally starting-pains will come on ; but these are mild, and do not 
form a subject of dread to the patient, or of special complaint, nor do mus- 
cular contractions form a prominent part of the disease ; nor does the gen- 
eral health suffer to any great extent. During the process of sequestration 
pain will recur with even greater violence, but with a noteworthy change 
in character. It is now due to the second, the ulcerative stage, by which 
the dead portion is separated, and in which, therefore, we should expect 
to find the symptoms approach more nearly to those of caries. Now, the 
sequestrum may lie in the middle of the spongy mass, or it maf be chiefly 
situated on some external part ; or, again, it may lie close to or include 
some portion of the articular lamella. These various conditions make a 
good deal of difference in the prospects and termination of the case ; hence, 
it is extremely important to be able to distinguish a necrosis from a caries 
of a joint-end, even before an external opening shall have been formed. 
The points of differential diagnosis may be thus given. 



232 



DISEASES OP THE JOINTS.. 



Diagnosis between Necrosis and Caeies in the Joint-end of a Long Bone 
during the earlier stages. 



Symptoms of Neurosis. 

Disease begins with a smart attack of 
pain and fever after an accident or ex- 
posure. 

Swelling equably hard, inelastic, bony ; 
an exaggeration of natural form lies close 
to integuments, which are adherent and 
seem thinned. 

The pain with which disease began sharp 
and severe, but soon diminishes very 
much ; then returns with other character 
— disease continuing all the time. 

If starting-pains come on they will not 
be very severe, and do not form a great 
subject of complaint. 

Permanent contractions are unusual as 
accompaniment. 

The general health does not suffer 
much. 



Symptoms of Caries. 

Disease so insidious in its attack that its 
actual commencement is difficult to fix. 



Swelling less hard and not equably so ; 
fluctuates obscurely in places ; the parts 
between bone and skin puffy, thickened. 



The pain begins less severely, but as 
long as disease lasts goes on increasing up 
to a certain point. 



The starting-pains very severe, and en- 
gross the patient's attention from other 
pains of disease. 

Permanent contractions constantly ac- 
company caries 6f a joint-end. 

General health very much injured by 
disease, sleepless nights, etc. 



Second Stage. — It is not a necessary sequence of necrosis, situated in a 
joint-end, that inflammation of the articulation should follow, because the 
dead bone may be situated so favorably that its separation can be secured 
without interference with the joint ; but it sometimes happens that a ne- 
crosis will inelude the articular lamella, or that pus, produced in the pro- 
cess of sequestration, destroying a portion of or perforating that structure, 
will find its way into the joint. If the necrosis have been so rapid that 
the synovial tissues up to the time of this occurrence are pretty healthy, a 
suppurative synovitis (more or less violent and acute) complicates the con- 
dition ; but, if the progress of the bone-malady have been so slow that the 
joint is already diseased, its cavity perhaps partially filled with pus, no such 
violent symptoms ensue ; the disease is very grave ; but it is subacute, 
sometimes chronic. I know of no symptoms which would clearly indicate, 
under these latter conditions, the exact period of eruption from the bone- 
cavities of pus or detritus into the synovial area ; nor indeed is it of any 
importance to distinguish the particular moment of such event. The 
symptoms above detailed and tabulated mark clearly the species of disease ; 
and, as we have seen, pus does not, unless the abscess be unusually acute, 
burst suddenly into a previously healthy joint ; but first detaches the car- 
tilage, or eats little openings through it, and so distilling slowly into the 
cavity, produces an equally gradual inflammation, which in large joints may 
be almost confined to the special part subtending the diseased portion of 
the bone. I have more than once resected the elbow-joint, as also the 
knee-joint, in which the inner or the outer side only was tilled with granu- 
lations, and the cartilages ulcerated. In these cases (necrosis) there is 
rarely any abscess in the soft parts at a distance from the joint, nor is any 
one point of the affected bone particularly tender until later in the case, 
when separation of the sequestrum by a process of caries commences. 

Caries implicates the joint even more slowly, but there is usually ovel 



CHRONIC OSTITIS. 233 

-the affected portion of bone a spot generally small and with conical pro- 
jection, soft and exceedingly tender, which at times becomes red and oc- 
casionally fluctuates. After awhile this little spot becomes larger, and 
fluctuation is permanent : it is a peri-articular abscess opening outward, 
and nearly always in more or less indirect communication with the seat of 
•caries. Very often, as in the case from which the figure is taken, a certain 
amount of posterior subluxation is contemporary with the formation of 
such abscess — partly because the spastic contraction of the flexors is now 
more potent, partly because the ligaments have become softened. 

Abscess among the deep muscles or creeping along the bone, even to a 
considerable distance, is common. These adjacent abscesses, if well sought 
for, may be found by tracing the limb downward with the finger-tips of 
both hands applied at either side. The bone thus compressed presents on 
one of its aspects a sudden hard ridge, which can hardly escape detection ; 
a similar increase of bulk among the muscles points clearly to intermuscu- 
lar abscess. The pus is not derived from the carious centre, but is the 
result of spreading irritation ; later on, indeed, the two foci may communi- 
cate. A distant abscess late in the disease generally originates in caries, 




Fig. 30a.— Ostitis of condyles.— Posterior subluxation. 

for slowly-formed pus burrows far among tendons and fasciae, breaking 
forth usually a long way from the diseased spot. The formation of matter 
among the soft parts is always accompanied by increase of pain and aggra- 
vation of the general symptoms. These are not relieved by opening the 
abscess ; on the contrary, they are rather aggravated. From the wound pro- 
duced by the bursting of the abscess flows at first flocculent pus, which after 
a little time becomes thin, watery, and of an irritating character ; it blackens 
silver and contains salts of lime. As the abscess empties, florid granula- 
tions crop out of the wound, forming the much-dreaded "proud flesh." 
In a little time the cavity of the abscess contracts, but only partially, leav- 
ing a passage or sinus, which may or may not lead, with many turns and 
windings, to the diseased bone. The granulations which crown these 
sinuses are deep red (crimson), and bleed very easily ; round the opening 
for some distance the skin is thin, contracted, and often has a peculiar 
purple look. The surgeon will naturally pass a probe into the sinus, and 
endeavor to feel therewith the rough surface of diseased bone, but it is 
very likely that he will not come at once upon such surface, either because 
the opening does not communicate with it or because the turns and wind- 
ings of the sinus, sometimes along a piece of fascia, sometimes round a 
tendinous sheath, may easily check the passage of a probe ; the bluish cir- 
cumference of a sinus filled with bright florid granulations is a sign so 



234 



DISEASES OF THE JOINTS. 



positive, that the mere fact of not being able at once to reach diseased! 
bone should not be allowed to negative its inference. A little patience 
and some ingenuity will, on a subsequent visit, find the proper channel ; 
but never for the mere sake of feeling the diseased bone should the probe 
be thrust violently through opposing structures. The bone is felt to be 
rough, but generally soft, and the friable cancelli yield a little to gentle 
pressure with the probe, the superficial portions breaking away. 

Diagnosis between Necbosis and Caries in the Joint-end or a long Bone; 

DURING THE LATER STAGES. 



Symptoms of Necrosis. 

When pus forms in the soft parts, and 
more particularly when it has been let out, 
the symptoms diminish. 



The sinuses are crowned by florid, but 
not brilliant, granulations, which do not 
bleed with extreme ease. They are sur- 
rounded by normal or slightly altered 
skin. 

The pus is not large in quantity, and is 
in general nearly laudable. 

A probe passed along a sinus to necrotic 
bone finds the passage tolerably straight 
and simple. The bone is hard, brittle, 
sometimes movable. Often one may feel 
the probe pass through a sinuous opening 
(cloaca) in bone before it comes to the 
dead portion. 



Symptoms of Caries. 

During formation of pus the general 
and local symptoms increase in intensity, 
and continue to increase even after an 
external opening has been made. 

The sinuses are crowned by florid bril- 
liant crimson granulations, which bleed 
extremely easily. They are surrounded 
by thin blue contracted skin. 



The pus is plentiful, thin, and irritat- 
ing. 

A probe finds the diseased bone-surface 
with difficulty on account of the windings 
of the sinus. The surface is rough, slight- 
ly yielding, not brittle, though parts give 
Way — it gives an idea of mortar-like soft- 
ness. 



There is a low form of inflammation of bone, which affects more often 
the cancellous than the harder parts, termed caries necrotica, which, as that 
name implies, is a mixture of both processes, comparable to phagedsenic 
ulceration of soft parts ; and as in those parts, either the sloughing or the 
ulceration may be the dominant action : in Fig. 28 is shown such condi- 
tion at the upper end of the tibia, ulceration being the chief but by no 
means the whole malady. .The necrotic condition may, after weeks or even 
months of caries, supervene upon the previously slow disease, and almost 
suddenly usher in great ravages ; perhaps-acute and violent suppuration of 
the joint, with danger to both limb and. life. Or the bone disease lying 
nearer to the epiphysal line may, while setting up less trouble in the joint 
itself, produce diastasis with singular deformity.' The following engraving 
is from a youth whose tibia, chiefly on the inner side, was affected with 
necrotic caries ; separation of the epiphysis had occurred. The disease 
had to a certain extent passed to the inner condyle of the femur. The 
joint outside the crucial ligaments (which formed a kind of septum), al- 
though very soft and to a great extent converted into granulation-tissue, 
was comparatively little affected. 

We will now turn for a time to certain forms of articular, or as it may 
here be termed, epiphysal ostitis, peculiar to early childhood ; since certain 
symptomatic peculiarities only appertain to that period of life during which 



1 The same result may arise from synovitis, see p. 108, 



CHRONIC OSTITIS. 



235 



the bone end is, save for an osseous nucleus, entirely cartilaginous. The 
parts which most frequently thus inflame, are the head of the femur — the 
tarsal bones — the femoral condyles — the head of the tibia — the bones abqut 
the elbow (most commonly the ulna, least so the radius) the epiphysal ends 
of the metacarpal bones. The disease manifests itself by hard, deep swell- 
ing — which surgically would be called bony enlargement, did we not know 
that the part in question is still almost entirely cartilaginous. At first this 
swelling, with or without considerable restriction of movement, more espe- 
cially in the direction of extension — perhaps even fixed flexion of the limb 
and considerable pain on movement, is all that can be detected. The in- 
fant hates and resents any handling of the limb ; but while at rest seems 




Fig. 31.— Caries necrotics of tibia (diastasis). 

comfortable. Such phase may be very transitory or may last for several 
weeks. Then, but by no means in the majority of cases, an acute suppura- 
tion of the joint, with great pyrexia, pain, exhaustion, and swelling, occa- 
sionally ending in rapid death, may follow. Such symptoms mark the rapid 
irruption of pus from an epiphysal abscess into the joint. The disease is 
most common ' in the first year or two of life ; but is not, as some instances 
under my own care show, confined to that period. At the hip, for instance, 
it may occur much later. 

If no acute symptoms supervene, the swelling and the restricted move- 
ment above described may go on for months, exceeding even the limits of 
the year. In certain cases, and these differences depend on the proximity 
of the inflammation to the joint-surface, very little change takes place, save 
increase of swelling and gradual extension of disease to the synovial mem- 



1 See Mr. Smith's oases in St. Bartholomew's Hospital Reports, vol. x., p, 189, 



236 



DISEASES 9F THE JOINTS. 



brane ; in other cases marked flexion and wasting of the limb, with nightly 
fits of crying, while still the synovial tissues are but slightly implicated, are 
the chief symptoms ; while, in still a third class, peri-articular and adjacent 
abscess form early. If s these open near the joint, the wound is particu- 
larly apt to enlarge into a rather wide, ragged ulcer, the skin surrounding 
which is often somewhat widely undermined, a condition, be it remarked, 
Tery different to the small sinus-like opening, that accompanies the ostitic 
abscess of later years, and which probably results from the slow production 
of the pus. Another peculiarity of this early stage is the extreme slowness 
with which the joint becomes involved (save under certain conditions already 
and again to be mentioned), a slowness not merely of time but of events. 
I have seen the femoral condyles, the olecranon portion of the ulna, the 
distal end of the metacarpal bone of the thumb and of the great toe very 
greatly enlarged, while the respective synovial membranes have been free, 
or very nearly free, of swelling or inflammation. 

At any point, even after the formation of adjacent abscess, the symptoms 
may retrogress— an event which is more common if the disease be about 
the hand or foot than in the neighborhood of a large joint The method 

and order of recession is this : first, 
the pain and tenderness decrease and 
disappear ; then the discharge (if any 
abscess opening have existed) gradu- 
ally diminishes, the surrounding red- 
dened skin contracts, and is drawn 
inward, and the wound heals. I ques- 
tion, however, if the cartilaginous 
swelling declines to any appreciable 
extent. A certain diminution of size 
about the part may be verified by 
measurement ; but it is very slight, so 
slight that it may be entirely due to 
decrease in the swelling and engorge- 
ment of soft parts. I have for years 
watched children who have recovered 
from this form of inflammation, and 
have found the limb remain larger 
than the other, until growth has ren- 
dered the proportion of difference less 
conspicuous — whether that difference 
be merely in circumference or also in 
length of limb. 

On the other hand, the nuclear 
ostitis may not recede, but go on to 
suppuration ; and now even more than 
in the ostitis of mature or advanced 
life the fate of the joint will depend upon the direction which the pus may 
take ; and this again depends upon the side or aspect of the osseous nucleus 
which was originally affected. If the pus pass outward away from the joint- 
■surface — as, for instance, happens occasionally at the knee just above the 
attachment of the lateral ligaments, or at the tibia on the inner side of the 
tuberosity, the articulation is not of necessity much involved — the abscess 
has passed along the epiphysal line. In these cases growth of the bone is 
for a time entirely stopped ; it nearly always is resumed, but only after 
.some months, and a permanent shortening very frequently remains. This 




ORtitis of tibial tuberosity, with short- 



CHRONIC OSTITIS. 237 

is often obscured by flexion, or some other malposition, and is less often 
detected than it would be if the limb were straight or capable of being 
straightened. 

I have verified in several instances — indeed, in all my cases of ostitis 
which have been followed by increased or decreased length of the bone — a 
condition due to changes at the junction between diaphysis and epiphysis. 

In giving the above account of symptoms, I have more particularly 
limited the description to disease as it occurs in the larger articulations, 
and indeed have had maladies of the knee more particularly before my eyes. 
Although the morbid history is identical for all large joints, it is in those 
■which are formed by smaller bones somewhat modified ; particularly if a 
number of such joints be included in one synovial membrane, and more es- 
pecially if they be very much surrounded by the dense tissue, which forms 
tendons and their sheaths. AH these peculiarities of structure and sur- 
roundings belong to the carpal and tarsal joints. When strumous affec- 
tion attacks such parts, the whole neighborhood is involved in brawny, hard 
tumefaction, which conceals the normally not very perceptible points of 
bone, and renders, in most cases diagnosis, as to the exact locality whence 
disease originated, very difficult or impossible. If synovitis pure and sim- 
ple ever attack these parts, the wide distribution of the membrane among 
the ossicles prevents limitation to any one spot. If the disease originate 
in a bone, the same anatomical arrangement diffuses inflammatory condi- 
tions to a considerable distance. As a matter of fact, primary ostitis, both 
at the wrist and foot, is very much more frequent than primary synovitis ; 
and yet at the carpus, until abscess and sinus form, it will generally be im- 
possible to distinguish more closely, than that the malady is at the inner or 
at the outer side of the limb ; while it is more often possible to recognize 
among the larger constituents of the tarsus which particular bone is in- 
volved. Abscess at the wrist may not — indeed generally does not — point 
close to the spot affected, while at the foot redness and tendency to the 
surface are frequently in the immediate vicinity of the disease ; yet some- 
times at a distance. Even when an opening allows the passage of a probe 
down to diseased osseous tissue, considerable acumen may be required to 
ascertain which of the bones has been touched. It is wise not to be con- 
tent, when disease has been found in one part, with a diagnosis that the 
malady is in that place alone ; every channel of the sinus track should be 
tested by very tender manipulation with the probe. Not unfrequently a 
single sinus mouth is the opening to various passages, each one perhaps lead- 
ing to a different bone. I may say here, though it hardly belongs to this 
part of the subject, that even after the most careful examination, made with 
the best skill, an operator will often prudently make his first incisions so as 
to leave him the choice of terminating his operation in one of several ways. 

We will return to the malady as it affects the larger joints. The phase 
now reached is that in which abscesses have broken or been opened in one 
or more places, near to or far from the articulation — through these open- 
ings diseased bone may be detected ; the synovial tissues are granulating ; 
the joint-cavity, what remains of it, contains pus. Even at this stage the 
disease may recede, in this wise : the sequestrum, if there be any, separates 
and comes or is taken away ; the carious surfaces cicatrize, the discharge 
diminishes, the sinus mouths retract their granulations, and even the skin 
around them puckers inward, the synovial swelling slowly disappears, and 
then with some amount of false or true anchylosis, perhaps with angular 
deformity, the joint heals. The resultant anchylosis, unless carefully treated 
by passive movement, is usually though not always a true one. As in stru- 



238 



DISEASES OP THE JOINTS. 



mous synovitis, retraction of the granulated tissues draws the skin close to 
the bone and produces depression of the healed sinus mouths ; but in these 
cases, moreover, the bone primarily diseased is generally left smaller than 
the sound one, both in circumference and in length. The annexed plate, 
from a boy aged eleven, who suffered in early childhood from ostitic joint 
disease, illustrates well these various points. He had a false anchylosis at 
a right angle, with slight subluxation, the sinus mouths were depressed, the 
tibia, measured from side to side with callipers, was nearly half an inch nar- 
rower than the sound one, and was just over an inch shorter. The femoral 
condyles were very slightly narrower, but absence of pressure in the nor- 
mal direction had permitted their 
elongation. There was no shorten- 
ing of the thigh. 

It must, however, be observed 
that occasionally a somewhat differ- 
ent condition pertains, in that the 
diseased bone remains permanently 
larger than the norm ; this appears 
to occur when a considerable amount 
of the tissue has sclerosed rather than 
softened. 

Accompanying, indeed sometimes 
preceding, this local improvement, 
considerable amelioration in the gen- 
eral health occurs, better coloration, 
softer and smoother condition of 
skin, cessation of irregular sweating, 
less suffering expression of counte- 
nance, and less pyrexia. The ther- 
mometer is . not only lower, but the 
temperature line is no longer so pre- 
cipitously serrated ; it is more even 
and regular in its smaller gyrations. 
Treatment— The preceding pages 
having shown, I think conclusively, 
that ostitic joint-malady not only can 
be, but, if we are to know and treat disease scientifically, must be, distin- 
guished from synovial affections, it becomes the duty of the present section 
to show how our knowledge may be utilized. 

General Treatment. — It may be asked if any internal remedies can bene- 
ficially affect an inflammation localized, like the one we have been consider- 
ing, to one little spot of the body. I can only answer by suggesting a 
side issue. If it be a cachexia which is keeping up the irritation, the ques- 
tion must shift its ground. Can we benefit a constitutional condition? 
Let me, as Sir B. Brodie was fond of doing, point to morbid states of the 
eye. Pew affections can be more localized than strumous conjunctivitis, 
with its photophobia ; it may go on for weeks in spite of blistering or 
drops into the eye, etc., yet a brisk purgation, usually with a little calomel, 
will sometimes clear it away in twenty-four hours. The form of struma 
with thick connective tissues is liable to peculiar formation of viscid mucus 
in the intestines, which prevents due nutrition and keeps up irritation. So 
again, when phlyctenulae have left small ulcers on the cornea, which are as 
local as any disease can be, some general remedies often prevail. 

Thus, a child with an enlarged and tender joint-end, but as yet with no 




Fig. 33. — Recovery after ostitis of tibia. Angu- 
lar false anchylosis. 



CHRONIC OSTITIS. 239 

joint disease, may be treated, if he have the thick unwieldy form of struma, 
with one or two purges of calomel, or gray powder and jalap, followed, if 
there he ascarides, by an iron and quassia injection. Alter this, if the child 
he large and strong, some such formula as two grains of gray powder, with 
one of quinine, night and morning, for three or four days ; after that the 
quinine may be continued alone or iron may be substituted. Iodine also' 
is especially useful. 

If epiphysal disease occur in a child, having the thin, clear, finely model- 
led struma, the malady tends to run through the first stages with greater 
rapidity than in the other variety. I think that hardly anything can be 
added to what has already been said (p. 120) concerning the general treat- 
ment of such condition. 

Local Treatment.— Rest, even in the early stage, must be enforced by 
means of a splint, as already sufficiently described ; but this need not be 
.so absolute and complete as is necessary in synovitis ; the question of irre- 
movable apparatus does not come before us until the joint itself is diseased. 

Ice, indeed any really cold applications, are injurious ; they increase 
deep hyperemia. Heat, best applied by salt-bags, not only affords relief, 
but is, in my experience, frequently beneficial, especially if used early, in 
oases due to some traumatism. This acts, I believe, by drawing the blood- 
supply toward the surface, therefore away from the bone, more especially 
from the deeper parts of that structure. 

The effect of blisters, or other revulsives, is, I presume, very similar ; 
their action may be carried somewhat farther than in synovitis, but not be- 
yond the commencement of vesication. Any bared surface should be al- 
lowed to heal at once, hence the blister should not be large, so that fre- 
quent repetition shall be feasible. 

A small line drawn with the actual cautery has, in my hands, often 
proved advantageous, and is more especially adapted to this form of disease, 
but to be useful, it must be applied before abscess has formed. The most 
convenient mode of application is by Petrequin's thermo-cautere, heated by 
the india-rubber pump to a white heat. The actual edge of the knife 
should be avoided by holding the weapon a little obliquely (sideways). 
The glowing platinum is then to be drawn rather slowly, with pressure of 
a few ounces along a line, each side of which is protected by two or three 
layers of thick, wetted plaster. As soon as the mark is made, and while the 
patient is still insensible, the plaster is gently taken off from the outer edge 
toward the burn, lest one remove with it an unnecessary amount of cuticle ; 
the place may then be thickly covered with flour or finely-powdered oxide 
of zinc, lint and bandage. The effect of this treatment in properly selected 
cases is to give immediate ease from the dull aching pain — startings, if 
there have been any, cease, and the burn gives no pain at all if the metal 
have been hot enough. Of course, in a certain number of cases, the suffer- 
ings due to the ostitis return (generally mitigated), but this is owing either 
to an error in selection or to inveteracy of disease. Again, I have known, 
even after a modified return, that the symptoms and the disease have slowly 
and gradually disappeared. 

Nevertheless, 1 would not wish to overpraise this treatment ; its applica- 
tion requires considerable judgment ; * it is most useful when the malady 

' In my first edition I spoke of the actual cautery more especially in reference to 
strumous synovitis ; herein I, misled by its marked effect on starting-pains, made a 
mistake: it acts upon the bone-hyperaemia, causing those pains, hence is useful in ostitis, 
whereas I looked on the relief of those bone-symptoms as a sign of its value in the 
synovial disease. 



240 DISEASES OP THE JOINTS. 

is not markedly localized to one spot of the bone, and when there is reason 
to believe that no suppuration has occurred. It is more likely to be bene- 
ficial in the slower than in the more rapid forms of disease, and when pain, 
almost absent in the day, comes on without throbbing, but with starting at 
night. 

"Whether or no the ferrum candens be used, extension should be em- 
ployed to the joints of the lower limb certainly, while to those of the upper 
it is of less importance ; chiefly, I suppose, because the muscles are less 
strong. The subject of extension must be considered with that of open air, 
of movement, or of quietude. A question in most cases most difficult to 
decide is that of rest or exercise, and it is one which permits of no general 
reply ; each case must be answered on its own merits. For instance, if the 
disease be in the upper limb, a splint should certainly be employed, but the 
child should be allowed to walk, even to run about ; also if it be in the lower 
limb — be of the chronic description, and do not as yet involve the joint, 
the expediency of keeping the child in bed is very doubtful. Certainly no 
weight must be supported by the limb ; but exercise may be given by driv- 
ing in an open vehicle, a swing out-of-doors, a tricycle worked by the 
hands, and in some cases by Thomas's arrangement of high-shoe and 
crutches, with or without one of his splints, according to the amount of 
joint-implication. I feel so assured of the ill-effects on infantile ostitis of 
confinement to bed and to the atmosphere of a sick-room, that I use any 
feasible expedient within my patient's reach to avoid it, from the homely 
perambulator to a couch in the square garden, a mattress on the beach, or 
an open landau. Even when considerable joint-affection is present, I, 
taking precautions against movement and displacement, still insist upon as 
much air as the place and season may afford, and as much exercise as can be 
procured without chance of moving or injuring the articulation. 

"Whatever means are employed for this purpose, some form of exten- 
sion should be used, at least during the night, and in any of the severer 
phases also during the daytime. American surgeons employ certain ap- 
pliances for making extension from strapping-plaster. 1 I will describe that 
for the knee, although I have failed, with great regret, to find it valuable, 
since all the plasters I have ever employed glide on the shin, and extension 
ceases in a few hours to be exercised. The instrument consists of two 
hoops, one for the thigh, one for the leg, connected at each side by rods 
capable of being lengthened by ratchet movement. The thigh is sur- 
rounded by plaster-strips, placed lengthwise, and the same is done for the 
leg, the knee being excluded. Both segments are bandaged, leaving un- 
covered five inches of the plaster at the top of the thigh, and at the lower 
part of the leg. Now the instrument is placed in situ, the ends of strap- 
ping turned over the hoop, and secured by the roller. "When all is adapted, 
the ratchet movement is said by Dr. Sayre to make sufficient extension to 
allow a child, apparently about eight years old, to walk without pressing 
the femoral and tibial surfaces together. In effecting this I have not suc- 
ceeded, as also I have been unable to devise any instrument which shall 
enable a patient to walk on the foot without throwing weight on the joints 
of his limb, unless such appliance runs the whole length of the extremity 
and gets its bearing at the perineum. Moreover, if the joint be sufficient- 
ly diseased to require permanent extension, the wisdom of permitting 
active locomotion is doubtful. The risk that the instrument may fail at 
some critical moment is considerable, or the patient may, through some 

1 Sayre'a Orthopaedic Surgery, p. 203. 



CHRONIC OSTITIS. 



241 



mishap of his own or of the appliance, fall, or merely stumble, saving 
himself by a wrench that may cost him his limb. 

The patient's leg and thigh may be secured in dextrine, water-glass, 
etc. ; and at night, either from strapping or the special stocking, weight- 
extension can be made. This is the simplest means, and often quite effica- 
cious and sufficient. But if the patient is to go out in the garden, or to 
drive, this cannot be managed unless the whole bed and apparatus be 
carried with him ; nor can weight-extension be used while he is lying on 
the ground. For such reasons an extension splint (Fig. 34) may be ad- 
vantageouly employed. 1 

The principle of its construction is to make a strong india-rubber 
spring, or accumulator, act as both extending and counter-extending force. 
For this purpose it is fastened by each end to a piece of catgut that plays 
round pulleys, attached to either end of the splint. I 
will describe particularly the arrangement for the knee. 

A Desault's splint, reaching from the middle of the 
trunk to two inches below the foot, is furnished at its 
upper part with a loop of strong wire or of steel (A), which 
carries a small pulley, and which projects outward about 
an inch and a half. The lower part is provided with a 
bar, running across the space of the notch, and also car- 
rying a pulley (D). From the lower end of the splint, , 
projecting inward an inch or an inch and a half, is another 
loop, carrying a third pulley (E). A perinseal band (B), 
passing round the upper part of the limb and splint, has 
a piece of rather thin catgut (violin string A or D) at- 
tached to it, which going through the upper loop of wire 
runs round the pulley (A), is brought down on the outsid6 
of the splint, and is attached to one end of the india-rub- 
ber accumulator (C). Another piece of catgut is attached 
to the appliance on the leg and foot ; it passes under the 
pulleys E and D, and is attached to the other end of the 
accumulator, stretching the india-rubber sufficiently to 
make what downward traction may be necessary. This 
splint holds to the limb by its own elastic force, and may 
be so used outside a starch or dextrine bandage. If 
it be employed as the sole appliance, it should be made 
rather narrow, and the limb is to be secured to it by one 
of the irremovable bandages ; or a similar contrivance is 
so easily adaptable to a back splint in the gutter form, 
that I need not describe the method here. 

If the signs of a distinctly localized ostitis be present, fig. 34. 

and it fortiori, if they be combined with those of intra- 
osseous abscess, the surgeon will consider whether he will be , wise to let 
the pus take its own course to the epiphysal line — perhaps loosening the 
junction — or, still worse, into the joint ; or, on the contrary, whether his 
hand ought to be the guide, which shall lead the pent-up matter to a harm- 
less exit. Bis conclusion must be based on several considerations ; 1. Are : 
the signs so distinctive that he may feel sufficiently assured of finding the 
abscess ? 2. Suppose he do not find it, will his procedure result in injury ? 
3. Is the place of redness or prominence, or both, so situated that he can 
reach it without damage to the synovial membrane ? 



1 A modification of this method is also used by Dr. Sayre for the ankle. 



242 DISEASES OF THE JOINTS. 

The first consideration requires two answers, according to the age of 
the patient. In very early life, while the bony centre is still small, the 
painful or swollen spot is sure to be on the same side of the nucleus as the 
malady, and it is barely possible — given a sufficient knowledge of baby- 
anatomy — to miss this spot. If the patient be full grown, or nearly full 
grown, it is indeed possible to miss the abscess ; ' yet these are generally 
not very far from the surface, and some further examination, soon to be de- 
scribed, may assist in detecting the locality of disease. 

The second consideration — the possibility of doing harm from failing to 
find abscess, need not seriously affect our practice. No surgeon would of 
course undertake such a measure unless the. symptoms were sufficiently di- 
rect ; but having such warranty, the fear of doing harm need not deter 
him. Even if at first the abscess elude his search, he may yet by a little 
tentative exploration find it, and failing that, he will nevertheless have 
done good. For the signs, which he has before him, denote tension within 
the bone, or, if an infant, within the cartilage. This is relaxed by a little 
opening, and benefit or, at the very least, relief from pain, always follows 
the procedure. (See Cases UK., LX., LXI.) 

The third question may best be answered while describing the opera- 
tion. But the surgeon must bear well in mind the exact line of attach- 
ment, which in different joints the synovial membrane follows. The head 
or condyles of the humerus can easily be reached from the front, avoiding 
the cephalic vein ; the olecranon and parts subtending the sigmoid notch 
of the ulna are easily within reach. Even the head of the femur is attain- 
able ; the condyles of that bone are best reached above either lateral ligac 
ment ; the head of the tibia from either inner or outer aspect of the tuber- 
osity ; the lower end also lies patent to surgical aid. The astragalus is 
easily come upon from either side. The surgeon makes, under a carbolic 
spray, a little deep crucial or T-incision in the part indicated for each joint, 
and either with a perforator, or a very small trephine-crown, pierces the 
bone in a direction toward the place of most projection, tenderness, red- 
ness, or whatever other sign leads him to suspect abscess. Let him re- 
member that he is dealing with a cancellous part, and that the opening, 
however made, need not go far, and but little force should be used. If he 
use the trephine, he should, on removing the piece, examine its further 
end for any sign of suppuration, softening, or indeed also of sclerosis. If 
no pus flow, a straight needle in a handle or holder may be used to ex- 
plore a little farther and on each side. A very soft part should lead to 
further perforation in that direction, as indeed should also any unnatural 
hardness, local abscess being often surrounded by sclerosed bone-tissue. 
Do not let him hasten this part of his work. "When the first weapon used 
has reached as far as seems desirable, he should take care to search with a 
fine needle thoroughly, but of course without doing unnecessary violence 
to the tissues. If the patient be still infantile, this search is not generally 
necessary ; the symptoms will have shown if the brunt of the inflammation 
be at the epiphysal line or at the centre of ossification. If at the former, 
the spot whither the pus is tending nearly always marks itself with suffi- 
cient distinctness ; if at the latter, the only point to be made out is the site 
of greatest tension. The most convenient instrument wherewith to perfo- 
rate the cartilage is a small "gouge, which, being turned as on a pivot, with a 
certain pressure removes a little-plug of cartilage down to the osseous cen- 
tre. If the diagnosis have been correct, a few drops of pus or of blood- 

'Holmes' Surgery of Childhood, p. 427; System of Surgery, vol. iii., p. 751. 



CHRONIC OSTITIS. 243 

stained serum flows away, and all the urgency of the symptoms cease ; 
whereas if the tension be unrelieved, suppuratkm, with caries or necrosis 
of the whole bony nucleus, is the almost inevitable result. I have often 
found great good and great relief follow this proceeding, even when only 
venous blood has come from the opening in the cartilage, and I have never 
once seen harm result. 

After the operation, a small drainage-tube should be. passed to the bot- 
tom of the osseous or cartilaginous wound, and the whole dressed antisep- 
tically ; the skin-opening should not have been large enough to require a 
stitch. Twice in my experience an abscess which had been missed opened 
into the bony channel in five and eight days respectively ; but should such 
event not occur, the drainage-tube may be gradually shortened, and in 
about a fortnight all will be granulating and nearly closed, the patient in 
the meantime having lost the pain, the swelling often having diminished. 
If abscess have been found and emptied, no further anxiety about the re- 
sult of the case need be felt, although progress, as in all bone-disease except 
the acute, will be slow. If, on the contrary, none have been detected, we 
must still watch, but the interference will very likely have prevented sup- 
puration, through relief of tension.- 

Let me not be understood to say more than I mean. It is not intended 
to assert, that in all cases of epiphysal ostitis the bone should be perfo- 
rated ; but that whenever such symptoms arise as lead the surgeon with tol- 
erable security to diagnose intra-osseous suppuration, an opening should 
certainly be made in the bone. No prudent man, be he parent or sur- 
geon, once assured that an intra-osseous suppuration exists, would let blind 
chance decide whether the pus shall find its way into and destroy the joint, 
while a skilful hand may assume the guidance of disease and lead it harm- 
less to a safe issue. 

If, after a time, whether the bone have or have not been perforated, the 
synovial membrane becomes inflamed, and if simultaneously or previously 
starting-pains come on, the surgeon will know that he has the fully devel- 
oped disease to deal with, and again must consider the possibility of benefit 
being derived from any of the means already described. Eest must now 
at all events be employed ; the more rigidly, the more acute be the inflam- 
mation. If the disease be in the upper limb, the patient is to be allowed, 
nay enjoined, to move about ; if in the knee or ankle, crutches and the 
high-shoe for the sound side may be advantageously employed, unless car- 
riage exercise can be obtained. The wheeled splint, which is a canvas gut- 
ter stretched between iron rods, attached above to an oblique ring, for the 
top of the thigh, and below to a couple of wheels, is a very useful appli- 
ance. 

When peri-articular or adjacent abscess form, it should not be allowed 
greatly to increase ; the former species, especially, should be dealt with in 
a sufficiently early stage. The opening should be free, but antiseptic ; and 
it is well to take the opportunity of examining into the condition of the 
bone. It may be that a carious surface, or a little opening, will admit the 
probe into a cavity containing perhaps simply pus, perhaps a sequestrum ; 
in either case exit should be given. If the patient have been chloroformed, 
and the position of disease render such procedure facile, it may be done at 
once ; otherwise it must be postponed until fitting arrangements have been 
made. Under no circumstances should a localized caries be allowed through 
mere want of initiative to spread toward the joint. A necrosis surrounded 
by abscess is to be dealt with as we deal with foreign bodies setting up 
suppuration. But we encounter here a question upon which surgeons 



244 DISEASES OF THE JOINTS. 

somewhat differ ; namely, whether or not it is wise to cope with such con- 
dition before the sequestrum has become loose. I myself am very decided 
■upon the point, that a sequestrum, clearly distinguishable from the neigh- 
boring living bone, should, if near a joint, be removed as soon as possible, 
thus avoiding the dangers of pus-accumulation in a cancellous bone without 
adequate outflow. Even if the sequestrum form part of the joint-sur- 
face, I still recommend its removal, for by this time the articulation, as 
an apparatus of motion, is destroyed ; delay can only add further risk 
to the patient's limb or life. Subsequent care must be taken lest the 
wound contract too readily, preventing free exit of discharges or of 
debris. 

With the exception, however, of keeping a careful watch upon the 
osseous conditions, and taking the earliest opportunity of removing dis- 
eased bone, or relieving suppurative tension, the treatment of the second 
and third stage of osteo-arthritis is, unlike the first stage, very similar to 
the management of strumous synovitis. In the later phases of both mala- 
dies we have to do with disease of both the hard and soft constituents of 
the joint. If suppuration and soft granulation produce tension, if the skin 
be white and lifeless-looking, we have yet a resource, before considering or, 
at all events, before proposing any method of removal, viz., free incision ; 
in ostitic disease the finger should afterward carefully investigate the state 
of the bone, the possibility of a sequestrum projecting toward the joint, 
the existence of intra-osseous sinus, and those other points already de- 
scribed. A perfectly antisepticized finger gently introduced through such 
an incision does no harm. Even if nothing indicating further remedial 
measures be found, it will have secured the absence of any septum of false 
tissue behind which pus may be stored. Nevertheless, when ostitic joint 
disease has reached this phase, it is, even with the resource just named, less 
hopeful than a synovitis in a similar state of suppurative decay. 

"When caries and necrosis affect small bones entering into the composi- 
tion of joints — such as those of the tarsus and carpus, even in young chil- 
dren the elbow — a somewhat different form of treatment is occasionally 
valuable ; as it may be substituted for excision, and, when successful, 
usually leaves a fairly useful limb. When abscess, especially if on both 
sides of the articulation, has formed, has been opened, and caries necrotica 
of the small bones or epiphysal ends has been verified, the surgeon, instead 
of removing or gouging the diseased parts, may draw, right through the 
joint and neighboring disease, a wisp of tenax, only taking care that the 
skin-opening is wide enough to let this He in the wound without tension, 
and indeed with a little room to spare. A free dischage of pus follows, and 
every other day, or more often, the oakum is drawn a little through the 
wounds. Very shortly the fibres entangle and bring away portions of ne- 
crosed bone, and after a time, if the treatment be successful, clears away all 
the diseased parts of bone, leaving healthy granulations behind. The con- 
dition of parts therefore must be from time to time investigated with the 
finger, and when it impinges no longer anywhere on bare bone, but on 
velvety granulation-tissue all around, the tenax must not at once be discon- 
tinued, lest some false healing and imprisonment of pus take place, but 
must be little by little diminished until a mere strand, and ultimately none, 
is left. He who has never used this method will probably be surprised at 
the rapidity with which, once the sequestra eliminated, even large gaps will 
fill ; therefore he must be very careful to keep the parts in a useful position, 
lest, before he is prepared for it, a twist or bend into some awkward pos- 
ture take place. 



CHRONIC OSTITIS. 245 

Case LIX. — James E., aged four, came under my care with disease of 
the knee, March, 1878. The joint was bent to little over a right angle, and 
any attempt to straighten it produced -violent screaming. There was some 
thickening of the synovial membrane, but the chief swelling was at the 
inner tuberosity of the tibia, which was much enlarged. The limb was 
• placed on a splint, and strong tincture of iodine was applied every morn- 
ing ; after the fifth application this had to be discontinued, and was re- 
applied three times after five days. 

March 13th. — The head of tibia was increased in size, and the knee was 
rather more swollen ; one spot on the tibia seemed especially tender, but 
there was some tenderness over the whole inner surface. For the last five 
nights starting-pains, marked by waking with a sudden scream, occurred 
several times. He was ordered three grains of iodide and three of bromide 
of potassium. 

April 5th. — Under the carbolic spray I cut down to the tibia, and 
with a small gouge removed a portion of the cartilage down to the nu- 
cleus. The Esmarch bandage having caused the soft parts to be dry, 
the escape of a few drops of blood-stained serum was evident. The 
wound was dressed antiseptically, a drain being left in the cartilaginous 
opening. 

April 20th. — A probe was passed into the opening, which was discharg- 
ing a thick creamy pus. The osseous nucleus, or a portion of it, felt to be 
necrosed and loose, was extracted with a pair of dressing-forceps. A good- 
sized drainage-tube was left in the cavity. 

May 16th. — The excavation in the cartilage gradually filling with granu- 
lation, drainage-tube was shortened, the synovial swelling decreased. The 
child recovered rapidly. 

Case LX. — Henry W., aged twelve, admitted February 26th into Char- 
ing Cross Hospital, under my care, with disease of the knee-joint. 

About four months ago he first noticed a little hard swelling on the inner 
side of head of right tibia. He was treated in a London hospital by iodine 
paint ; the part still enlarged. About a fortnight ago the knee-joint itself 
became painful, and he could not move it well. 

The enlargement on inner side of tibial tuberosity was considerable, 
the skin over it slightly red. Very severe pain, irregularly paroxysmal, 
was generally followed by swelling of the knee, which afterward sub- 
sided if there were three or four days' interval without the pain ; but the 
attacks were becoming more frequent, the knee was getting stiff, also en- 
larged. 

March 11th. — The swelling both of the bone and the joint was evidently 
increasing. I therefore cut down and trephined the head of the tibia. There 
was a tolerably thick layer of cartilage ; and when the bony nucleus was 
reached, some serum, slightly blood-stained, flowed away. 

April 1st. — There was no sickness, pyrexia, nor pain. The bony enlarge- 
ment slowly but persistently subsided ; the knee-joint was normal. 

April 24th.— Left for a convalescent home, the wound having healed, 
and the only abnormal condition was a somewhat enlarged tibia. 

Case LXL — Percy F., aged eleven, admitted under my care into Charing 
Cross Hospital, February 24, 1880, with diseased knee, which had been 
going on for five years. It had been nearly painless, except when abscess 
about the outer side had formed. The last of these commenced three weeks 
previous to admission, and burst, leaving two ragged ulcers, the larger 
about the size of a shilling. 

The knee was considerably enlarged, the synovial tissues a good deal 



246 DISEASES OP THE JOINTS. 

thickened ; the chief increase, however, being about the outer condyle. The 
outer tuberosity of the tibia was also slightly enlarged. 

Eight knee at level of patella 12f inches. 

Left 10£ " 

The joint was almost immovable. There was no tenderness, save on the 
outer condyle. 

March 4th. — I laid the two openings into one. There was no sinus lead- 
ing to the bone ; I cleared the soft parts and examined its surface, but 
could find no cloaca ; yet one spot was soft, so as to give a sense of being 
impressible by the nail. Here I applied a small trephine, and opened a cav- 
ity in which lay a loose necrosis of the cancellar portion. A little enlarge- 
ment of the opening was necessary, in order to remove the sequestrum, 
which was the size of a small Barcelona nut. The operation was performed, 
and the boy dressed antiseptically. He had no temperature or other bad 
symptom, and after the first three days hardly any discharge. 

On the 23d the wound nearly healed and granulating ; antiseptics dis- 
continued. 

March 27th. — Drainage-tube left off. 

April 1st. — Convalescent. 

Case LXH. — Jane R, aged thirteen, came under my care into Charing 
Cross Hospital, May 3, 1874, with disease of the ankle-joint, from which she 
had suffered intermittingly for about four years, at which date, it appears, 
she received a kick on the inner ankle-bone. 

The whole surroundings of the joint were much swollen, with the anklet- 
like appearance of joint-affection. The enlargement ran only slightly up 
the leg, but extended behind and below the malleoli more than half-way to 
the sole and to the tip of the heel, in front as far forward as the medio- 
tarsal joint. The swelling was soft, chiefly marked on the inner side, where 
increased size of the lower end of the tibia was perceptible, more especially 
in front, where the malleolus joins the rest of the bone. Here, evidently, was 
the chief seat of disease. The prognosis beiDg very unfavorable, the joint 
was nevertheless enveloped in plaster-of-Paris, first surrounded by two layers 
of wadding. She was sent to the sea-side. 

June 9th. — The plaster splint was renewed in the interval, and at the 
above date was taken off. The general swelling was somewhat harder ; but 
in front, just above the joint, and behind at the outer side of the tendo- 
Achillis, abscesses were pointing. These were opened, and a probe passed 
from the front one into the tibia, from the back one into the articulation. 
The foot permitted of abnormal movement at the ankle-joint, and bony 
crepitus was distinct. A careful examination verified the absence of bony 
crepitus in the tarsal bones, except the astragalus. 

June 22d. — Excised the joint. On examining the truncated surface of 
the tibia an abscess was seen, in the centre of which was a sequestrum 
which had been divided by the saw. It ran some way up the bone, through 
the epiphysal line, and, as far as could be judged, appeared to commence 
on the distal (the epiphysal) side of that line. The articulating surface of 
the tibia was quite bare of cartilage, save on the malleolar surface, and in 
most parts the articular lamella had given way. Through two of these 
openings the osseous abscess communicated with the joint. The astragajus 
was also denuded of cartilage, except on the lateral surfaces. The synovial 
and perisynovial tissues were stuffed with and converted into granulation- 
tissue, which also invaded the tendinous sheaths lying behind the tibia. 



CHRONIC OSTITIS. 



247 




Flo. 33.— Ostitis of tibia. 



The child did well ; the termination of the case is reported in Chapter 
XX. I cannot but think that had it been possible to detect the abscess ear- 
lier, and to perforate the bone, a chance of saving the joint might have been 
afforded. 

Case LXHL— Emma G., aged nine, came under my care into Charing 
Cross Hospital, July 10, 1877, with diseased knee. 

The child was tall, thin, and ill-nourished, but not cachetic. The right 
knee was considerably swollen. Examination, however, showed that the 
synovial membrane and soft structures of the joint were but slightly 
affected, while the inner tuberosity of the tibia was 
considerably enlarged. This part was tender on 
pressure, and at one point more especially was a 
slight increased projection where tenderness was ex- 
treme. The knee was movable through a small 
range, but beyond this the muscles contracted spas- 
modically, the child screams and says it hurts her, 
referring the pain to the upper end of the tibia. 

July 19th. — I made a T-incision over the point 
of most swelling, turned aside the flaps, and with 
the scalpel cut out a circular piece of cartilage down 
to the bone ; at this point the probe showed the 
osseous tissue to be soft and pultaceous. All this 
softened part was removed with a gouge, nor did 
I desist until the probe, unimpeded, struck on healthy hard tissue. A 
drainage-tube was placed in the opening, the antiseptic dressing applied, 
the knee placed nearly straight on a splint. 

July 21st. — There had been, since the operation, neither pain nor fever. 
August 17th. — The wound — with the exception of a small part, the exit 
of the drainage-tube — was healed. The slight swelling of the synovial mem- 
brane had greatly diminished. 

October 2d. — On my return to town I found the child well. The inner 
head of the tibia was still a little large, and doubtless would remain so for 
some months. It was not tender unless the scar was directly pressed upon. 
The swelling of the joint itself had quite disappeared. The limb could be 

moved without pain through 
very nearly its entire arc. 

Case LXIV.— William But- 
cher, aged twenty-eight, from 
Alford, near Guildford, came 
into the Charing Cross Hos- 
pital, March 13, 1860, with 
disease of the right wrist. 
fig. 36. About ten months previ- 

ously the wrist became pain- 
ful ; he thought he sprained it, and tried pumping on it. At last, not being 
able to work, he had to go to the Union : the medical man lanced the wrist 
once and applied linseed poultices. Starting-pains came on about a month 
after the beginning of the disease. The wrist was much swollen and shape- 
less; the tendinous sheaths, both at the back and in front, participating in the 
swelling ; the whole was puffy and doughy, with harder and softer parts'; 
the end of the ulna was enlarged ; over the back of the metacarpal bones 
of the index and ring-finger behind there was a greater tumefaction, which 
fluctuated ; over the back of the unciform there was the mouth of an old 
sinus. 




248 DISEASES OP THE JOINTS. 

It was explained to him that there was little probability of being able 
to save the wrist ; but before having recourse to the last resort he wished 
to have some means tried. It was determined to use the actual cautery, 
though without hope of cheeking the suppuration then going on in the 
bones. Accordingly, under chloroform, three lines were drawn with the 
hot iron. 

April 16th. — The cautery lines all healed ; but, as expected, no improve- 
ment took place. 

May 5th. — I amputated about an inch and a half above the wrist-joint, 
and afterward examined the part. 

Examination. — Tendons of extensors with their sheaths of thumb and 
index healthy ; common extensors matted together by soft tissue and sup- 
purating ; an abscess over commencement of metacarpal bones of index and 
middle finger, which had not penetrated through the skin : flexor tendons 
also matted together and suppurating ; tendons of extensor carpi ulnaris 
sound ; periosteum over the end of the ulna much swollen and puffy ;.the 
bone itself carious all round, studded with holes and little osteophytes. All 
the bones of the carpus surrounded by pulpy tissue of synovial membrane ; 
articulating surface of the radius deprived of cartilage, rough, carious, and 
covered with pink pulpy tissue (granulations). First row of metacarpal 
bones on the surface, where they articulate with the radius, carious, deprived 
of cartilage ; on their other articulating surfaces partly deprived of carti- 
lage and carious ; in some parts the cartilage still remaining was thin and 
sodden, here and there detached from the bone : the semilunar and the 
scaphoid were quite soft, converted into a fleshy mass with thin network 
of bone running through it. The second row of bones were also carious, 
but in a less advanced condition, more of the cartilage remaining than on 
the first row ; the cartilage throughout could be stripped off like thin tough 
membrane, and left beneath a pink pulpy material (granulation from the 
cancelli). 

Microscopic. — The synovial . membrane was converted into a structure 
consisting entirely of round, nucleated cells, bare nuclei, and granules ; the 
tissue upon the bones in the absence of cartilages, also that which was left 
when these were stripped away, was precisely the same. The cartilage it- 
self, thus thinned, had, for the most part, undergone fatty degeneration ; 
the cells were in some places full of oil-globules ; in other parts, and these 
next the free edge, the whole corpuscle was full of oil, the cells having ap- 
parently, deliquesced ; in other parts of the section the condition was one 
of atrophy, the corpuscle and the cells being very small ; the hyaline sub- 
stance is fibrous wherever the cells are fatty. 

The carious bones had their cancelli filled with pulpy granulation-tissue 
and pus ; the bony walls very plainly laminated ; lacunae enlarged, light, 
full of nucleated cells ; canaliculi large, as a rule ; Canada balsam penetrated 
very easily. 

The following case occurred before I had conceived the idea of paracen- 
tesis ossium. I believe that much time might have been saved and risks 
avoided had this means been used. 

Case LXV. — Alice Blackman, aged six, came to me at the Charing 
Cross Hospital, December 14, 1859, with pain of the right knee. 

The only change in form about the joint was that the inner femoral con- 
dyle was somewhat protuberant ; on examining it by touch the tissues over 
that part were found thickened : the child cried with pain when the joint 



CHRONIC OSTITIS. 



249 



was moved : more particularly if it was either bent or straightened beyond 
a certain point. Pressure upon the inner condyle produced more pain than 
equal force exerted on the other. The child was fat, dark, coarse-featured, 
with swollen lips, red edges to eyelids, and large joint-ends to the bones 
generally ; the left knee, sound, was inclined to bow inward. She was 
ordered to take a purge of calomel and jalap ; to have a splint, nearly 
straight, applied to the outside of the thigh and leg ; a blister above the 
seat of pain ; to be dressed with the iodide of potass ointment. 
' • December 30th.— The child came back as directed on the 16th. She 
had been getting better, but at this date the complexion was thick, the 
breathing short, and throat stuffed with mucus ; there seemed, also, more 
paiu in the joint.— Ordered another purge of calomel and jalap ; when its 
action was over, to take quinine and gray powder. 

January 6, I860.— She took the pills for four days ; much better, less 
heavy, complexion clearer. Keturn to the quinine 
and acid ; to paint the inside of the joint with tinc- 
ture of iodine. 

February 17th. — The child well ; the joint has 
not been inflamed. 

June 8th. — Alice Blackman fell down-stairs, and 
came back to the hospital with some little injuries; 
she at the same time hurt her knee, and the pain 
in it makes her cry a good deal, especially at night. 
The inner condyle was altered in shape, as could be 
detected by the sense of touch ; but it was hardly 
more protuberant ; it was tender on pressure and. 
hot. She cried when the knee was moved more 
violently than before. A nearly straight paste- 
board splint to the outside of the thigh and leg ; 
a blister above the inner condyle ; to be dressed 
with zinc ointment ; iodide of potassium mixture 
to be taken three times a day. 

June 20th. — She had another blister over the 
seat of pain ; there was less tenderness, but the 
child cries at night a good deal. It appeared that 
she did not wake up suddenly, but had some diffi- 
culty in going to sleep ; when she woke, she did so 
with effort, and cried. It was evident that these 
were not the starting-pains, but only the dull aching of the earlier stages. 
Ordered to paint the joint with tr. iodinii ; to continue the mixture, and 
to return for a week to the tonic medicine. 

June 25th. — There has appeared over the most prominent part of the 
inner condyle an increased tumefaction, which fluctuates ; the fluid is deep. 
There are at present no pains which appear like starting of the limb. The 
joint was drawn at this time. 

July 2d. — The whole joint was swollen and puffy ; the enlargement did 
not depend upon fluid effusion .in the cavity, but on peri-articular thicken- 
ing ; the tenderness over the inner condyle rather less. The child looked 
better. Apply blister round lower part of thigh in front. 

July 6th. — The pain over the condyle, and the fluctuating swelling, ap- 
peared less ; but as the peri-articular tissues were implicated, I desired to 

The abnormal projection of the inner condyle is somewhat increased by a serous 
effusion under the periosteum. 




Pig. 37. — Ostitis of inner con- 
dyle. 1 



250 



DISEASES OF THE JOINTS. 



treat, also, that condition. Gave the child chloroform, and applied the 
cautery-iron in one line at the outside, two at the inside of the joint. 

July 20th. — Child better : the wound from cautery almost healed, and 
much less tenderness about the joint. To take one tablespoonful of quinine 
mixture three times a day. 

August 17th. — The joint had been strapped tightly for the last ten days, 
and the splint removed ; the child had ceased to cry at night ; the inner 
condyle was scarcely, or not at all, more susceptible of pressure than that 
of the other side, and the peri-articular fulness has disappeared. » 

September 19th. — The child's joint perfectly sound. 

Case LXV1— Jane Dickery, aged thirteen, a thin, weak-looking child, 
having finely cut features, small bones, and veins plainly marked about the 
mouth and temple, was brought to me May 30, 1860, with the left shoulder 
painful and swollen. 

The swelling was very evident ; it made the shoulder look rounder, 
larger than the other, and somewhat pointed in front, and a little to the 




Fig. 38. — Strumous ostitis of the head of humerus. 



outer side. This was best visible when the patient sat upon a low seat and 
the surgeon looked down upon her from above, thus obtaining much the 
same view as is given in the accompanying drawing, which was taken with 
the child lying on her back. The shoulder was tender on pressure, and 
hot. She was ordered a teaspoonful of cod-liver oil, and two tablespoon- 
fuls of quinine mixture, three times a day ; a blister to the front of shoul- 
der ; the arm to be bound to the side. 

June 9th. — Appetite improved. She had, since last report, a blister 
behind the shoulder : a superficial abscess formed over the acromion of the 
other side. 

June 16th. — Again a blister to the front of the shoulder ; to be dressed 
with oxide of zinc ointment. 



CHRONIC OSTITIS. 251 

June 30th. — Better : the abscess over the right acromion had broken 
and left a superficial ulcer : to let the blister heal ; the arm no longer to be 
bound to the side, but to be kept in a sling. 

July 13th. — The shoulder diminished in size very much ; it was neither 
now tender nor hot. Passive motion and friction. 

September 7th. — There was some trouble in overcoming the stiffness, 
and difficulty in moving the shoulder ; but it was ultimately rendered as 
freely movable as a healthy joint, though the head of the humerus did not 
regain its normal size, but remained little larger than normal. I procured 
an admission for her to the Walton Convalescent Hospital 



CHAPTEK XII. 

ARTHRITIS DEFORMANS. 

Pathology. — The more usual names for this disease — Chronic Rheumatic 
Arthritis, Rheumatoid Arthritis, or Rheumatic Gout — appear badly adapted, 
since they all connote a pathological relationship, which is, to say the least, 
not proven, and because they fail to indicate the chief characteristic of 
a disease in which the bone-ends are frequently so altered that heads 
which should be globular are flattened and broadened to the shape of toad- 
stools; cavities that should be' spherical are shallow or' ovoid ; capitella 
change to hollows ; trochlea become pyramidal ; and sigmoid notches span 
twice their normal grasp. On these altered joint-surfaces little or no ves- 
tige of cartilage remains ; the bare bones, in places polished, are studded 
with little openings, like worm-holes. The necks of long bones shorten 
and change their direction, while from them and even form the shafts 
sprout irregular osteophytes, which, interlocking with those from the 
neighboring bone, form buttresses and struts, greatly impeding or prevent- 
ing motion. Therefore that a joint-inflammation (an arthritis) is present 
may be with certainty affirmed ; the participle " Deformans " is well chosen, 
and indicates the strange, even grotesque, results of the disease. 

The first mention of the malady dates back to a hundred years ago ; for 
in his short clinical history of the " Nodosity of Joints " (London, 1805), 
Dr. Haygarth says : " It is about twenty-six years ago since I wrote a de- 
scription in a paper " — which was read at a small professional society in 
-the "West of England— in the year, therefore, 1779. He speaks of it as "a 
troublesome disease of the joints, clearly distinguished from all others by 
symptoms manifestly different from the Gout, and from both Acute and 
Chronick Rheumatism." He goes on to say that the disease has occurred 
in 34 out of 10,549 patients ; is almost peculiar to women whose catamenia 
are ceasing. In the 34, only one was a man, aged between fifty and sixty, 
who had the nodosities only on the fingers, he having fallen on the hand a 
short time previously. Women have more joints affected, principally, how- 
ever, the fingers. " They (the nodosities) more commonly attack persons 
in the higher and middle class of life." 

It is, however, chiefly to two Dublin surgeons, Mr. R W. Smith and 
Mr. Robert Adams, and to my colleague Mr. Canton, that we owe valuable 
labors and much minute investigation of the disease ; and to the last named 
more especially the explanation of many instances of deformed joint-bones 
which were previously considered, sometimes as the result of peculiar dis- 
locations, sometimes of a bastard gout or syphilis, sometimes simply — and 
here Mr. Canton's investigations are more especially valuable — as the re- 
sult of senile change. 

The disease is essentially one of later life. Although a few cases occur 
before the age of forty, they are exceptional, and are then a sequela of some 
febrile attack, or of disorders of menstruation. Moreover, it is more com- 



AETHRITIS DEFORMANS. 253 

mon among men than among women, and affects the poorer rather than the 
upper ranks of society. The discrepancy in this statement with the de- 
scription of Dr. Haygarth is only too striking. With regard to the class of 
society, it will be remembered that the practice at Bath was, as now, chiefly 
among persons capable of bearing the expense of a stay in that city, and 
therefore Dr. Haygarth saw people from a distance affected with gout and 
rheumatism, or symptoms ascribed to those diseases ; while the poorer per- 
sons of the district itself are, from the nature of the climate, not -very prone 
to the disease. For the difference in regard to sex it is difficult to account ; 
something may be due to a mere fortuitous concurrence of female cases ; 
something to inaccurate diagnosis ; for Dr. Haygarth does not appear to 
have examined any cases anatomically ; or, again, it may be possible that 
the larger indulgence in stimulants, especially in port wine, practised at 
that time by the well-to-do males, may have developed into true gout what 
would otherwise have culminated in Arthritis deformans. At the same 
time it must be well known to every practitioner that women of all classes, 
but chiefly, I think, of the upper classes, whose catamenia have ceased 
rather suddenly, especially rather early, are very prone to this form of dis- 
ease. However that may be, there is no doubt that males of the poorer 
class are most of all subject to the malady, and that its chief habitat is a 
damp, chilly climate. ' I have not heard Of any instance of its occurrence 
in hot or dry places, such as Hindostan, Spain, etc. Most commonly the 
disease is poly-articular, but may also be set up in a single articulation by 
injury, such as fracture into or close to a joint, even by severe blow and 
strain ; and from this one spot the action occasionally travels to other joints. 
Thus it is evident that the disease, though usually constitutional, may also 
he merely local. When constitutional, the immediate provocative is usually 
a long exposure to damp and chill, more especially if combined with scanty 
food ; or a very much less exposure when the system has been depressed 
by some fever, be it exanthematous or rheumatic. Again, a certain number 
of cases occur without any traceable cause whatever. Once fairly and fully 
established, the disease suffers no abatement ; treatment may retard the 
progress — may indeed prevent the spread to other joints — but once fully 
set up in any articulation, it hardly permits of much alleviation ; the altera- 
tions in form, when once they have taken place, are irremediable. 

The most conspicuous of the changes fall upon the bone ; but it is im- 
possible to give here an exhaustive account of their infinite varieties. The 
key to them lies in the unstable ratio between atrophy and hypertrophy. 
The former takes place where there is pressure, the latter where there is 
none. A convex joint-surface may thus grow in breadth by marginal ad- 
ditions, while the central parts, subjected to pressure, may become flat, 
even hollow. But if position or a strut-like growth prevent pressure, such 
a surface may assume an almost conical shape. Similarly variable condi- 
tions may cause a cavity to become either deeper or more shallow. 

Peri-synovial and ligamentous tissue are in the earlier stages simply in- 
flamed and thickened ; later, this thickening in most parts is greatly in- 
creased, the tissue becoming like fibro-cartilage, or yellow ligament. In 
other parts considerable absorption may have taken place, so that a large 
ligament, like the internal lateral of the knee, may be left as a few more or 
less disconnected shreds. Later on, both in parts that have suffered ab- 

' Sir Benjamin Brodie describes it as being common among the upper servants, hall 
porters and tall footmen, of large London houses ; but a perusal of hi# cases leaves no 
doubt that he did not clearly distinguish this malady from gout proper. 



251 DISEASES OF THE JOINTS. 



« 



sorption and in those that have undergone thickening, there takes place ii 
many cases a singular growth (not a mere calcareous deposit) of bone, whicl 
commences at the attached border of the capsule, and gradually spread 
more or less over the whole structure, so that the joint-ends may be de 
scribed as enclosed in an imperfect and fragmentary sheath of bone. Somi 
of these fragments are provided with a thin layer of cartilage facing th 
joint-cavity. Thus, we have three phases : 1. Mere inflammation. 2. Thick 
ening with condensation in some parts, and absorption in others. 3. Bon; 
metamorphosis. In any one of these conditions it may be observed tha 
the whole capsule is enlarged either from a pre-existing hydarthrosis, o 
from a peculiar bony growth, to be described hereafter. 

Intra-capsular ligaments and tendons rapidly disintegrate or become ab 
sorbed. This is perhaps most markedly exemplified by the ligamentun 
teres of the hip and the long tendon of the biceps, a little less conspicu 
ously by the crucial ligaments of the knee. These ligaments are either en 
tirely or only partially absorbed ; being detached at one end (at the hi] 
generally, from the femoral, at the knee from the tibial), they are fraye< 
out and unravelled. The intra-articular pari of the biceps tendon is eithe 
absorbed, and the lower end gets a new attachment in the bicipital groove 
or it is dislocated inward, or it is split up and flattened, its separated fibre 
passing in various positions over the head of the bone. The cotyloid liga 
ments both of shoulder and hip are, according to R Adams, quite absorbed. 
I believe them to be quite as frequently converted into bone, and I posses 
a specimen, a traumatic case, in which such ossification is evident in th 
cotyloid ligament of the hip. Intra-articular cartilages are, as a rule, ab 
sorbed, though more rarely they may be found ossified, even hypertro 
phied. 

The Synovial Membrane is, like the subsynovial, thickened ; and man; 
of the bony growths above mentioned protrude into it, or rather througl 
it, so as to take its place here and there, the surface which is toward thi 
joint lying bare in the gap of membrane. In the earlier phases it is red 
the vessels being gorged with blood ; later, the general surface is paler 
Around the margin, where it joins the bone, very large papillary growth 
sprout in the greatest luxuriance, sending forth secondary buds, some o 
which contain cartilaginous or osseous bodies, more or less sessile, onl; 
attached by a thin stalk, or just ready to break away and become loose 
These are (see Chapter on Hydarthrosis) hypertrophied synovial fringes 
and are usually confined to the points above mentioned ; but occasionall; 
the whole inner surface of the membrane is thus covered, presenting a sin 
gular hirsute appearance, like a sheepskin mat. 

Cartilages. — The tissue-changes of cartilages are very singular, and ii 
many points unlike those that occur in any other disease ; unlike not onl; 
in their nature, but also in the strange admixture of atrophy, hypertrophy 
ossification, fibrillation and fatty degeneration occurring in patches through 
out the structure. We may, however, localize somewhat these processe: 
thus : hypertrophy, which is, as we shall see, much mixed up with bone 
changes, hereafter to be discussed, takes place as a rule where there is n< 
pressure, chiefly, therefore, at the edges of the structure which grow out 
ward— i.e., centrifugally, often in a more or less regular, frequently in i 
most irregular manner ; we will call this marginal hyperplasia. This newl; 
grown part ossifies rapidly, giving rise to the ensheathing or to the nodosi 
form of overgrowth (Figs. 39 and 40) ; mingled with this hyperplasia an 

1 On Rheumatic Gout, p. 33, econd sedition. 



ARTHEITIS DEFORMANS. 255 

patches and lines of fatty degeneration. In these spots the cartilage rapidly 
disintegrates and becomes absorbed, the chasms thus produced helping to 
divide the craggy projections from one another, and aiding the nodose ap- 
pearance. Those parts of the cartilage which are exposed to pressure 
undergo, not throughout the whole structure, but in places here and there, 
inflammatory atrophy, fibrillation and ossification from the deep surface. 
Thus, a certain part will be converted into bone, in the middle of which a 
patch of fibrillated cartilage will be found ; while, next it, perhaps, may lie 
some remains of cartilage, still smooth but excessively thin, because ossifi- 
cation has reached from its depth almost to its surface. The fibrillation is 
peculiarly coarse, the cartilage corpuscles are greatly enlarged and filled 
with proliferating cells. The ultimate outcome, however, of these changes 
is that by one or the other process, or rather by all of them intermingled, 
the joint-cartilage ultimately disappears from both surfaces, leaving the 
naked bones to rub against, to polish, or to roughen each other, according 
to their mutual juxtaposition. 

The Bones undergo such remarkable changes that the morbid anatomist's 
chief interest must be concentrated upon them. They are inflammatory 
hypertrophy and atrophy, so intermingled as to produce, together with the 
marginal cartilaginous hyperplasia, the most singular changes of shape, 
and, in a certain sense, peculiar alterations of structure. Hypertrophy 
takes two forms, either interstitial (induration) or enlargement. Atrophy 
may either be exhibited as rarefaction or absorption. 

Of hypertrophies, the interstitial variety takes place where there is fric- 
tion ; it is therefore found where two surfaces move on one another. It 
gives to the bone an extreme density, termed eburnation, or porcelanous 
deposit, and enables it to take a high degree of polish ; it is merely a sur- 
face condition. In certain ways it is different to the osteo-sclerosis of or- 
dinary inflammation, being in part produced by deposition, in the Haversian 
canals and other natural cavities, of bone-earth barely mixed with 'organic 
parts, but in the finest subdivision. This deposit is sometimes so abundant 
as to strangulate the vessel of the canal. It is often combined with abso- 
lute diminution of size, or "wearing away," as some have called it ; also 
it is generally in mere small patches, scattered among other patches of 
rarefaction. Hypertrophic enlargement is chiefly mixed up with the mar- 
ginal hyperplasia of cartilage, yet takes place ab initio in any spot* which, 
by the growth of neighboring parts, may have been relieved of pressure ; 
for — and I cannot too strongly insist upon this fact — the changes of form 
in the joint-surfaces proper are the result of adaptive hypertrophy and 
atrophy, regulated entirely by pressure. 

A very singular phenomenon, resulting from the naked condition of 
bone-surfaces, combined with interstitial hypertrophy or eburnation, is the 
fine polish which continued friction induces. Sometimes these burnished 
plates are on rather small scattered blotches, but more generally in spots 
of larger size, or in lines of alternating depression and elevation — ridge 
and furrow. In hinge-joints, as at the knee, these lines run on tibia and 
femur, from before backward ; on the patella, from above downward. In 
arthrodial joints they assume a spiral or cycloid shape. Often they may 
be demonstrated as a polishing of the ossified articular cartilage ; in other 
cases they are situated on the bone-structure proper, whose cavities have 
been filled up by interstitial deposit, which are nevertheless undergoing 
dimensional atrophy, and on which very frequently the worm-holes left by 
extinct Haversian systems are somewhat plentiful. This admixture of in- 
terstitial induration, together with wasting and diminution in size, is very 



256 



dIseases of the joints. 



singular ; and yet so constantly are they both associated with wear and 
polish of surface, that we may almost affirm, whenever we see burnishing 
of bone or of ossified cartilage, that there is taking place not only the ill- 
organized porcelanous deposit, but also diminution in size. 

Interstitial atrophy, although it always accompanies, must be distin- 
guished from dimensional atrophy, because it also takes place in parts 
which are not decreasing. It is marked by increase in size of all the nat- 
ural cavities, until what was solid bone becomes a mere reticulation of thin 
lamella? ; a change best seen on section, while on the surface this condition 
is chiefly marked by round holes, like those in worm-eaten wood. They 
are the places whence Haversian systems have disappeared in whole or in 
part. Such holes may be in the midst of eburnated bone, leading to re- 
ticulate spots of atrophy ly- 
ing next to or immediately be- 
neath a layer of burnished 
porcelain. As the polished lay- 
l^^^H^UiHlik. er wears awa y> new deposit on 

•^P^v^*^*!* * - *lSwPllS^. ** 8 deep surface takes place, 

and thus the eburnation en- 
croaches on atrophied, and 
this latter on healthy parts, 
the bone-tissue itself gradu- 

W TW& PES ^*# ;V W SS i a ^ v disappearing. 

fl ril^^^^^^^^^^K 19 These two forms of hyper- 

trophy and of atrophy, com- 
bined with what I have called 
marginal hyperplasia, may, by 
the careful study- of speci- 
mens, recent and otherwise, be 
shown to effect all the changes 
of form characteristic of this 
disease, which, though so va- 
rious, are all produced and 
carried out on one and the 
same plan. Thus, at the knee 
here depicted, irregular mar- 
ginal hyperplasia is more es- 
pecially marked, the result 
being a craggy outgrowth of 
additamentary bones, which 
surround the joint proper, and 
by their buttress-like action preclude movement, without anchylosis, which 
never or very exceptionally takes place in this disease. This form of hyper- 
trophy (marginal hyperplasia), which produces, according to certain cir- 
cumstances, either this craggy or a peculiar ensheathing bone-formation, 
(see Fig. 40) takes place thus. As soon as the inflammatory act has reached 
the stage at which the cartilage begins to participate, the cells of that struc- 
ture proliferate freely. Where the bones exercise a mutual pressure, this 
action leads to absorption of the tissue, as we have just seen ; but at the 
margins, where there is but little or no pressure, and where the vascular 
supply is large, the excited cells gather around them new hyaline matter, 
so that this margin, growing centrifugally, either overhangs or encases the 
bone near the joint-surface ; or, if the irritant be more potent, produces a 
crop of uneven nodules which might be termed ecchondroses, did not ossi- 




— Marginal hyperplasia (after Canton). 



ARTHRITIS DEFORMANS. 



257 



fication follow close upon the cartilage growth. This conversion into bone 
takes place with great rapidity from the deep surface, while growth still 
goes on from the superficial face. Until the whole knob is ossified, growth 
continues ; so that during the progress of the disease these lumps are, in- 
ternally and on their deep surface, bony ; superficially, cartilaginous. The 
older ones, which have stopped growing and lie nearest the joint-surface 
proper, are generally in contact with similar outgrowths from the fellow- 




>. , 



■91 




FiGt 40«»OStitifl deformans. Plates from margin of the head ensheathing the neck. 

bone ; these two parts coming in contact mould each other by mutual 
pressure into dovetailed forms, which act as a kind of outriggers to the 
true articular faces, increasing and adding to their breadth in every direc- 
tion. ^ It must be remembered that this hyperplasia takes place from the 
margin of the articular cartilage, i.e., from a part within the synovial mem- 
brane, and that the resultant growths are therefore within that structure, 
which they, however large they may become, push outward and distend. 
17 



258 DISEASES OP THE JOINTS. 

Herein they differ from those osteophytes, which are frequent in other 
joint diseases, which are merely deposited by the periosteum, and which 
are extra-articular. Now, if with this broadening out of the margin, be 
it of a head or of a cavity, considerable absorption, in the former instance, 
or hypertrophy in the latter, be combined, we see very plainly how it hap- 
pens that rounded heads like that of the femur or humerus must necessarily 
become flattened or mushroom-shaped, while acetabular or glenoid cavities 
become wide and shallow. But such changes of form do not stand alone ; 
they are associated with change of place ; for instance, the acetabulum mi- 
grates upward and backward, so as to lie above Nelaton's line. That is to 
say, that at the upper part, most exposed to pressure, atrophy takes place, 
the bone is absorbed at that point of the periphery, while downward and 
forward, where there is no pressure, bone is deposited, and thus the whole 
cavity shifts its position. 

But most singular are the changes occurring at the head of the femur, 
which are such that the* bone looks as though its neck had been absorbed, 
and had become so soft as to yield to the weight of the body, and to bend 
down to a right or acute angle with the shaft. I need scarcely say, that 
this is not the real explanation of the abnormal form — the truth being not 
that the neck, but that the head of the bone is absorbed, and that what, in 
the fully developed disease, takes the place of the head is an enormously 
hypertrophied neck. Let me refer to Fig. 40, from a specimen I have 
chosen, because it represents the malady in a form just far enough ad- 
vanced to indicate the method of change. In that drawing, the border of 
the joint-surface is prolonged outward by marginal hyperplasia and encases 
the neck of the bone, while the round worm-eaten little holes on the upper 
aspect of the head indicate that atrophy at this part has commenced. The 
ovoid form of the caput which looks due to growth in length is a prolonga- 
tion of bone from the cartilage margin over and upon the neck, chiefly in- 
deed on its lower aspect. The next phases are increased absorption of the 
upper aspect 'of the head, and fresh growth at lower part of neck, the re- 
sult being that the head falls to a lower level and encroaching on the neck 
lies between the trochanters. The appearance is as of a head sessile and 
depressed upon the trochanters ; the reality is a head almost entirely ab- 
sorbed and replaced by a tumid neck. Like changes take place at other 
joints ; among them at the metacarpophalangeal and at the inter-phalan- 
geal joints. They very often commence quite early in the disease, affect- 
ing by hypertrophy and atrophy the outer and inner sides respectively of 
the first-named articulations, so as to press the fingers over to the ulnar 
side. In the further development of the disease at this place very singular 
and characteristic distortions are produced. 

Carefully as I would avoid, when possible, differing from such an au- 
thority as Professor Volkmann, I cannot agree with his reasoning from these 
facts that the malady commences in the synovial membrane, though it is 
true that clinically the first appearance is often a synovitis with effusion. 
The fact that adjacent bones such as the acromion and coracoid process 
participate in the action, and even aid in forming the abnormal socket, 
and that inflammation, identical even to the formation of tufts, takes place in 
the neighboring tendinous sheaths, preclude the possibility that such 
widespread influence can arise from mere synovial irritation. "When, too, 
we look at the microscopic illustrations to Sir J. Paget's paper " On Ostitis 
Deformans," ' and at the bones involved, we cannot help observing a re- 

1 Med. Chir. Transactions, vol. lx. , p. 37. 



ARTHRITIS DEFORMANS. 259 

markable similarity, although the irritant of movement being in that case 
absent, because the shafts and not the joint-ends were attacked, no addita- 
mentary bones were formed. 

On the other hand, one may, as I have akeady stated, doubt the exis- 
tence of such a thing as a " panarthritis," if by that term be meant an in- 
flammation which attacks simultaneously and equally every one of the joint 
structures. 

I would- rather ascribe the malady to ostitis, originating in some con- 
stitutional cachexia, which resenfbles the rheumatic in its tendency to fibril- 
lization, thickening, and organization of new products rather than to their 
puriform degeneration. We must wait, however, before we can justifiably 
apply to this disease the name of chronic rheumatic ostitis, until we know 
with more precision than at present what the words rheumatism and rheu- 
matic really mean. 

Symptoms. — It is of great importance that a disease, which so alters 
and cripples perhaps a great number of joints, and which when fully 
established is so little amenable to treatment, should, if possible, be recog- 
nized in its very earliest stages, and this is a matter requiring great care 
and experience, since at first the objective symptoms are very few. The 
practitioner should remember that although the disease is more usual in, 
it is by no means confined to, elderly persons, nor to any particular class 
of society ; that, unless traumatic, it generally attacks several joints, but 
that nevertheless one joint only may be diseased long before another is im- 
plicated ; that it is not necessarily preceded by attacks or by hereditary 
history of either gout or rheumatism, and that alteration in the form of 
the joint is a comparatively late symptom. 

The disease, if mono-articular, is usually, if not always, preceded by local 
injury, varying from a bruise or sprain to a fracture or dislocation. If 
poly-articular, it may be preceded by acute rheumatism, exposure to cold, 
loss of health from mental depression or other influences, changes or defects 
of the menstrual function, habitual dyspepsia with acidity and other causes 
of lowered vitality ; while again in many cases no possible preceding or 
accompanying abnormal condition can be detected. The first symptoms, 
if the malady arise from rheumatic fever or from such exposure to cold as 
shall produce a sudden suppression of perspiration, are much more acute 
than when a less potent causality exists. One or more joints, the knee, 
shoulder, metacarpal-phalangeal joints, most usually thus attacked, are 
painful, red, and swollen ; there is also some pyrexia, and the highly acid 
urine will be loaded with lithates ; the swelling, like that of rheumatism, is 
chiefly peri-articular. Doubtless some intra-articular effusion also occurs, 
but this is small in amount, except at the knee, where it may exist in con- 
siderable quantity. Such malady may be easily mistaken for a mild attack 
of acute rheumatism or of gout ; or if it follow such attack, may be con- 
sidered a relapse after some days' interval ; but the temperature is much 
less, the skin is rather dry than bathed in acid perspiration, and the 
malady in this febrile form lasts but a few days ; even the joint- affection 
may abate. 

If, as is more usual, the disease commence at once in its chronic form, 
much obscurity will be found in its earlier stages. The patient complains 
of a painful stiffness, generally at first in only one joint. This may even 
somewhat diminish ; while another joint becomes attacked, and even a third, 
when all the earlier troubles recur with aggravation in the one first affected. 
Such cases are often considered* simply as "a little rheumatism." I have 
heard them described as creeping and senile rheumatism. One case, which 



260 DISEASES OP THE JOINTS. 

appeared to depend on sudden cessation of the lacteal secretion, was de- 
scribed to me as " milk rheumatism ; " and more than one occurring in 
the hands have been sent to me as subacute gout. At this period the dis- 
ease, when ( the limb is at rest, is but slightly painful ; nor have I found 
that patients thus affected complain of that peculiar pain on getting -warm 
in bed which the truly rheumatic describe ; but in many cases, especially 
if one or more of the large joints be involved, the patient is much troubled 
by starting-pains. . On the other hand, the painful stiffness is most marked 
after a night's 1 rest, or after any continued repose, when the patient first 
tries to move. The skin over the affected joint is often pale, even cool ; 
there is no high temperature even at night ; perspiration is usually scant 
and difficult ; the urine often quite normal, though sometimes too acid, and 
loaded with lithates. 

In the very slow progress peculiar to this disease no further perceptible 
change may occur in the articulations save the implication of another joint 
or two ; but the limb becomes rapidly wasted and the muscles flaceid. 
This occurs in the case of the knee, above rather than below the affected 
joint ; while at the hip the emaciation invades buttock, flank, and thigh 
At this period the diseased joints become somewhat limited in their move- 
ments ; the hinge-joints, for instance, incapable of complete flexion or ex- 
tension ; the balL-and-socket joints of full rotation move especially inward, 
which movement is, rather than the outward, painful. It is remarkable 
that while normal movements become thus limited, abnormal mobility is 
frequently developed ; up-and-down movement, for example, of the heads 
of femur and humerus within their cavities, sideways movement of knee or 
elbow. Indeed, in a few cases, lameness is due more to abnormal mobility 
than to fixity of the joint. About the time* when limitation of normal" 
movement commences, and always before the establishment of abnormal 
mobility, crepitation in the joint may be detected ; crepitation, evidently 
bony, and due to the absorption of cartilage. This, like the stiffness, is 
more marked on using the limb after a^ period of rest ; it is sometimes so 
harsh and loud as to be heard by a bystander. At this stage, too, occur, 
most markedly when the hand or foot is affected, the first slight beginnings 
of those deformations which afterward become such conspicuous features 
of the disease ; the changes in the hand, to be described in the sequel, be- 
gin to be traced out so delicately that probably only a much-experienced 
eye can detect the deviation. 

Swelling may have occurred, indeed usually does occur, previous to the 
changes described in the last paragraph, but the precise period of its 
advent is very uncertain. Mention has already been made of the fact that 
when preceded by acute rheumatism, or when the malady commences in an 
unusually acute manner, peri-articular swelling puts in an early appear- 
ance, and even synovial enlargement may likewise occur. When, however, 
the malady commences in a chronic form, synovial effusion is, in my ex- 
perience, a later symptom, and is often absent or imperceptible until the 
stiffness has gone through its first stage of mere sensation, that is to say, 
until some real limitation of movement is discoverable. I make this state- 
ment with some little diffidence, because Professor Adams, undoubtedly 
one of the very greatest authorities on this subject, says, " in the early 
stages of this affection the principal enlargement of the .joint arises from 
the effusion of a large quantity of fluid into the synovial sac ; " ' but the 
cases which he gives by no means bear out this assertion ; indeed, in 

1 Loc. cit. , p. 12. 



ABTHRITIS DEFORMANS. 261 

several, long-continued lameness is described before any swelling is noticed. 
The knee may on this point be somewhat exceptional, for hydarthrosis is 
said sometimes to culminate in arthritis deformans. Yet such event- 
must be rare, for I do not know of a single case of this sort of synovitis 
among the very many that I have treated which has so terminated. Nor, 
on the other hand, do I know of any case of the deforming arthritis which 
could be traced to a hydarthrosis, though swelling, often considerable and 
doubtless synovitic, has come on some months or even years after continual 
stiffness has been established. 

Even, however, before any very distinct enlargement of the synovial 
membrane occurs, there will be felt, if the surgeon make pressure with his 
finger over the joint and move the deeper structures to and fro, a peculiar 
sensation comparable only to the sound of a rustle — what the French term 
" frou-frou ; " it is like rubbing two silken surfaces together between the 
finger and thumb. This sort of crepitation may be very fine or coarser, 
and is produced by the passage of a roughened synovial membrane over 
other parts of the joint. It is not peculiar to the malady now under con- 
sideration, but only indicates a condition of membrane which is present in 
this as in certain other diseases. Of course it is only perceptible in super- 
ficial joints. I have frequently felt it in the knee, occasionally in the elbow 
and in fingers. Care must be taken not to mistake a similar crepitation, 
which is very common in the patellar and olecranon bursa, for a roughness 
in the joint itself. When, however, the disease has advanced to the stage 
in which the shape, size, and position of bones have altered, hard, irregular 
enlargements, Haygarth's nodosities, are easily detected, and at the same 
time the position of the limbs becomes changed. These changes have been 
'in the preceding division of this chapter partly described. I will therefore 
only briefly consider the various postures. 

Shoulder. — The head of the humerus is prominent in front, and appears 
also lifted, while a depression behind seems to indicate progression for- 
ward of the head and its deficiency at the back ; the patient cannot lift the 
arm from the side nor rotate it. Great pain is produced if the surgeon 
execute these movements passively. Usually in this joint abnormal mobil- 
ity exists ; the arm can be drawn down till the head lies even below its 
normal level, and in tolerably advanced cases crepitus will be felt in all 
these movements. The shoulder is more prone than any other joint, save 
the hip, to traumatic causes of arthritis deformans. 

Elbow. — There is no especial diagnostic position ; it is one of the joints 
least liable to be affected alone, and by itself — a great aid to diagnosis. 
Synovial effusion with false bodies, and development of abnormal bursse in 
the neighborhood, occur after the disease has continued some months, and 
I think earlier than in other joints. 

Wbist and Hand. — The articulations of these members are more often 
attacked than any others, probably on account of their exposed condition, 
and the distortions produced are very characteristic of the disease. On the 
dorsum the wrist looks remarkably hollow from the radio-carpal articula- 
tion to the base of the metacarpus. The lower ends of the radius and ulna 
project considerably, the projection being most marked in the latter, which 
also is often much enlarged. At the metacarpo-phalangeal joints, as they 
become involved, singular and pathognomonic distortion is produced, the 
fingers being considerably adducted, so that the index forms at its radial 
side a salient angle with the metacarpal bone ; often that finger, usually 
the first attacked, crosses the middle one on its dorsal aspect. The thumb, 
When involved, is usually strongly flexed on the metacarpo-phalangeal 



262 DISEASES OP THE JOINTS. 

joint, the phalangeal extended. The adduction of the fingers is so marked 
and characteristic a symptom, that it at once gives to the experienced its 
own solution : exceptions, however rare, occasionally occur, but neverthe- 
less even these exceptional positions have a distinctive type, and will not 
be easily mistaken. Cases of mult-articular 'disease, which might otherwise 
present diagnostic difficulties, may be at once traced to their true source 
by a study of the wrist and hand. The various joints become after a little 
time enlarged, and studded with uneven, hard projections — nodosities, as 
Haygarth called them. 

Hip. — Shortening, partially real but chiefly apparent ; ' limb usually 
rotated outward, divergent from its fellow ; nates of affected side flattened 
and flaccid ; considerable lameness. Voluntary flexion and rotation are 
very limited, the latter more especially in the inward direction. If the 
surgeon cause such movements, considerable pain is produced, and crepi- 




FlG. 41. — Early arthritis deformans. 

tation is nearly always perceptible. Some abnormal mobility usually ex- 
ists. The thigh can be drawn downward, and on cessation of traction it 
will be seen to rise again. The patient experiences great pain on walking, 
if he throw his weight on the affected limb, but no pain on pushing the 
heel up, or thrusting the trochanter toward the joint, which differentiates 
the disease from ordinary coxitis. 

It is to be remembered that of all joints the hip is most usually alone 
affected, indeed the term malum coxce senile originates from that peculiarity. 
When mono-articular at the hip, the affection is often traumatic. The 
eversion of the limb, the shortening and the crepitus, are often a cause of 
embarrassment in diagnosis. If a person, of whom the surgeon previously 
knows nothing, but who has for some time suffered from arthritis de- 
formans, come to him after a fall or severe blow on the hip, he will prob- 
ably be at first led to diagnose intra-capsular fracture ; and even when pre- 
vious history arouses a suspicion of other disease, he may find it difficult to 
assure himself that fracture does not also exist ; for the two are by no means 
incompatible. 

Knee. — Abduction and outward rotation of the tibia, increase in breadth 
of the patella, which also tends to lie outside its normal position ; rapid 
■wasting of thigh, and, less rapid or complete, of leg. Enlargement from 
synovial effusion is either earlier at this joint, or, on account of its super- 
ficial position, is more readily detected. After the subsidence of the secre- 
tion, sometimes before its advent, the synovial rubbing or rustle can be 



1 For the full exposition of these real and apparent conditions, see Chapter on Hip 



Disease 



AKTHRITIS DEFORMANS. 263 

easily felt, and loose bodies in the joint detected. Earlier than at other 
joints, except the fingers, can osteophytes, or at least rough bony excres- 
cences around the joint, be clearly felt. It would be well to state that cases 
of increased synovial effusion with roughened membrane, even with one or 
two false bodies, are not to be ascribed to the disease in question, unless 
the above-described mal-postures of tibia and patella can be verified ; un- 
less abundant growth of osteophytes can be distinguished ; or, again, unless 
several other joints are thus arthritic. 

Ankle and Foot. — Of all the joints in the lower extremity the metacarpo- 
phalangeal joint of the great toe is most often affected ; then the medio- 
tarsal joint (generally with some other tarsal or tarso-metatarsal articu- 
lation), and least often the ankle. But it is to be noted that when the 
disease has invaded one of these small joints, it spreads pretty rapidly to 
others. The hallux is thrown outward, so that the head of the metatarsal 
bone becomes salient and nodose. But this position is so constantly a 
mere effect of wearing pointed shoes, that such posture is not, as in the 
hand, diagnostic ; even some grating in the joint may be merely a local ef- 
fect of bad shoeing. Other joints of the same or opposite foot, and of the 
hands, must be studied. At the medio-tarsal joint the disease produces an 
enlargement which runs round the whole waist of the foot, and is especially 
marked on the inner side by 
projection of the head of the ^mms*. 

astragalus and scaphoid — after —e^' "tlllWSsh. 

the manner of flat foot. The t ' IPW. 

enlargement of the whole cir- r_ ' 'vJ^S\d£££g£i&<s*>' 

cunit'erence of the tarsus — the | mjs£' WjStm^ 

fact that the outer border of the ™f^~ IJJIIllP 

foot, though it loses some of vXjL^^^S^, 3PHi§ 

its convexity, is not concave, as ^B|llr%LsiP* '' ^^8 

in the slighter forms of valgus ^^^^^rj^^^amt^^^^^S^ 

— will afford sufficient points (^ ^S'^asSto 

for diagnosis. Moreover, some 

effusion into the sheaths of the Fla - ^--Arthritis deformans (after Canton). 

neighboring tendons usually 

takes place in arthritis of the tarsus. The ankle is rarely the seat of this 
disease, and still more rarely is alone affected. The chief symptoms are an 
appearance of width between the malleoli, while each malleolus in itself 
is increased in breadth from before backward. Tendinous sheaths are en- 
larged. The stiffness produced by ankle-joint arthritis, especially if com- 
bined with tarsal disease, causes a heavy, clumsy, and noisy gait ; also, to 
avoid as much as possible movement of those articulations, the patient in 
walking everts the foot considerably ; when, however, he is placed at rest 
with the legs horizontal, the eversion vanishes. This is a very characteristic 
symptom. 

In the above descriptions of the malady I have, as far as possible, con- 
fined myself to those appearances which are the first, or at least very early, 
objective symptoms. "When the disease is more fully advanced, when the 
joints are not only crippled but deformed, often grotesquely by outgrowths 
and nodosities, no tyro would hesitate in forming a diagnosis. If we take, 
for instance, the hand here depicted, an exact counterpart of which came 
under my notice in an old lady during October, 1876, or if we imagine the 
gnarled, swollen joint produced by such an altered skeleton as that depicted 
at p. 256, it seems unnecessary further to describe the local characteristics 
of this disease. The gradual increase of stiffness, the invasion of a greater 



264 DISEASES OP THE JOINTS. 

number of joints, the almost entire helplessness which such condition in 
the end produces, furnishes a distressing and a hopeless picture. More 
especially painful is the condition when, among others, the temporo-max- 
illary joint is involved, rendering mastication a difficult and distressing 
process. 

Yet in a certain number of such cases the health is frequently remark- 
ably good. Sometimes it appears as though the malady arose from super- 
abundance of functional and digestive powers ; the appetite is perfect, diges- 
tion easy and even rapid, but with occasional acidity ; bowels rather costive, 
with scybalous motions ; sleep sound ; complexion fresh and rosy ; skin soft 
and moist. "We may find that in some of these functions a little super- 
abundance prevails — somewhat too much of food and too little work — 
such cases seem to have been those which chiefly came under the observa- 
tion of Sir B. Brodie. We may discover, on strict inquiry, that there is 
some acidity and flatulence, a great tendency to sleep after meals, a loose 
condition both of muscles and skin, a tendency to the accumulation of soft 
fat and a greasy, unctuous condition of surface. Such comfortable func- 
tional performance may continue to the very end of the disease, even when 
the patient is set fast and incapable of moving any joint in the body. 
Some years ago I occasionally was called to see a lady, the joints of whose 
lower jaw, one shoulder, and perhaps one or two of the vertebral articula- 
tions, were the only ones unaffected ; the hips and knees were perfectly 
fixed. In one arm and hand there was sufficient movement for her to feed 
herself ; she was every morning lifted out of bed into a chair, every evening 
back again to bed, without altering the angle of the thigh and body, or of 
the knees. Yet she enjoyed, so far as the performance of all bodily func- 
tions, except movement, is concerned, perfectly good health, with the ex- 
ception of slight acidity after food. With the exception of her joint-trou- 
bles and occasional indigestion, I do not think she had a day's illness for 
the last ten years of her life. She died simply of old age, at the age of 
eighty-one. 

The more usual systemic condition, however, is that of debility, to 
which some external depressant has been superadded ; exposure to cold and 
damp, insufficient and ill-adapted food, weakened powers of digestion, de- 
rangement of menstrual function, or even mental disquietude and sorrow. 
In such instances the marks of -a lowered health will be found ; the acidity 
which is usually present will be traceable to an atonic rather than to an 
over-fed state of stomach. The urine, generally much too acid, will be 
found loaded with lithates — alternating occasionally with a neutral phos- 
phatic condition. The skin is dry and harsh ; feet and hands liable to be 
cold. The patient at first wastes rapidly up to a certain point, and does not 
recover the lost flesh. Such instances are of course more common among 
the poorer classes, but occasionally among the well-to-do. Whatever be the 
bodily condition, even in the very worst cases, it never appears commensurate 
with the amount of local mischief. 

Treatment. — In proposing a name new in England for this disease I am 
not actuated by any love of mere change, but by a desire that names such as 
rheumatic gout and rheumatoid arthritis may not, by influencing our views 
as to the nature of the disease, involve any corresponding ideas of treat- 
ment } for neither by such regimen as would benefit gout, nor by many of 
the remedies we should employ in rheumatism, can any good be effected in 
arthritis deforrnans. 

When the malady commences in an acute or subacute form, especially in 
any febrile action, more particularly if the urine be too acid and contain 



ARTHRITIS DEFORMANS. 265 

lithates, we may advantageously employ febrifuge, but not debilitating rem- 
edies. The skin being hot and dry, or simply dry, would indicate one 
of the salts of ammonia — the effervescing citrate in the formula already 
given, the citrate of potash or the spirit of nitrous ether. Indeed, all this 
class of remedies will be found useful in restraining the pyrexia, and allevi- 
ating the acidity both of the primse viae and of the urine. An aperient 
sufficient to produce a free, but not a large action of the bowel, should also 
be administered, but violent action — purging — should be avoided. 

Of special remedies in this phase of disease I have but to mention a 
few. Colchicum is, I believe, injurious, save a single dose of the extract 
given as an alterative, or cholagogue, with the cathartic. Iodine should be 
avoided till the fever is past. Salicine does not appear to me to exert any 
marked influence in this disease ; it neither alleviates pain nor lowers the 
temperature, as it does in the much more febrile and painful condition, 
namely, acute gout. I speak, however, from a somewhat complex experi- 
ence, and since the time when that drug came into vogue I have seen but 
few cases in their simplicity, and so unsophisticated by previous drugs as to 
be fit subjects for deduction. Nor is there any great need of a special rem- 
edy. This particular phase of the disease may be in a few days subdued 
by such medicines as above indicated, but more by rest in bed. By rest, 
I mean not merely lying down, but almost absolute quietude of the affected 
joints ; even nicely adapted splints, pillows under the knees, slinging one or 
the other leg, etc., may be employed to produce such immobility of the in- 
flamed parts as may be obtainable without absolute coercion. We shall see 
by-and-by that in further advanced stages of the malady rest is not so de- 
sirable, but in this, the more acute phase, it very much checks the advent 
of further symptoms, and may postpone them indefinitely. Another advan- 
tage of confinement to bed, while pyrexia continues, is the preservation of 
an even temperature, a most important part of the treatment, especially if 
sudorifi.es be exhibited. 

To any joint more especially painful, particularly if it be hot with swell- 
ing of peri-articular tissue or of sheaths passing over it, from one to four 
leeches, according to its size, may be applied ; but such treatment must 
not be repeated often enough to debilitate. Hot water, or, still better, hot 
solution of bicarbonate of potash, about £ drachm to the ounce, may be 
used as a bath for fifteen minutes ; or flannel soaked in a much weaker so- 
lution may be kept under thin mackintosh to the part. To this a little 
hydrocyanic acid, about twenty minims to the ounce, may be added, and, 
what has often appeared to me efficacious in relieving pain, as much cam- 
phor as can be dissolved in a drachm of spirit. Belladonna also may be 
advantageously used in the same way. Conium, too, and opium may be 
employed ; but in all these I consider the bicarbonate of potash as the most 
valuable ingredient, as having a real effect on the morbid condition ; the 
others act only by subduing pain and irritation. 

A light but fairly nutritious diet should be given, and certain persons 
whose free digestion and large appetite (see p. 264) cause them to consume 
much meat two or even three times a day, must undergo some modification 
of habit ; but this must be effected with caution ; even though the patient 
seem in strong health, the correlations of this disease with debility must 
not be overlooked. Unless the fever run unusually high, a little claret, or, 
what is better, unless it disagree with the stomach, a little old, pure whiskey, 
in preference with hot water, or with potash or soda-water. 

When this acute phase has passed, the disease will fall under the same 
mode of treatment as though it had been from the first chronic ; and in 



266 DISEASES OP THE JOINTS. 

either case we have to consider two somewhat different conditions: that which 
performs the usual functions of life easily and which appears well nourished, 
and that which is marked by a spare, ill-nourished and depressed system. 
Nevertheless, in both cases the malady is essentially one of debility, and the 
desirable varieties of treatment relate to different proportions rather than to 
different kinds of remedy. All medicines having a tendency to depress the 
system must either be entirely avoided or used with the utmost caution, 
and although the action of the bowels generally requires some regulation, 
drastic purges are forbidden. The perchloride of mercury in small doses, 
and not long continued, has, in my hands, proved beneficial ; it may be com- 
bined with iodine or with other drugs, as we shall shortly see. Iodine, either 
by itself or with iron, is very valuable (Formula I.). Guaiacum is more es- 
pecially useful when the skin of the hands and feet and of the affected 
joints is cold and clammy — combination with ammonia appears to increase 
its value. 

As already stated, I consider this malady one of debility, hence any 
form of tonic is useful. Iron, either combined with iodine, or given as the 
perchloride, with the same salt of mercury — quinine, strychnia, are all useful 
Arsenic, too, is occasionally followed by improvement ; but I cannot extol 
the remedy to the same extent as did the late Dr. Fuller ; indeed, its action 
requires close watching, lest it disorder the digestion and produce liver 
troubles. "With these remedies a light but nutritious diet should be or- 
dered, and a certain amount of stimulus may be administered. 

Among the most valuable remedies, as Dr. Haygarth long ago pointed 
out, are baths. If circumstances do not permit the use of natural hot 
baths, even simple hot water, or hot water with carbonate of soda or potash 
are very useful ; they appear to act by recalling the function of the skin, 
and in some unexplained way check the progress of disease. More valua- 
ble by far are certain natural hot waters ; those of Buxton, Harrogate, 
Bath, and Tunbridge, in England, are most commendable. On the Conti- 
nent are many — Vichy, Carlsbad, Aix, Barruges. 

The use of mineral waters internally is efficacious, and my experience 
points more particularly to the Woodhall Spa Bromo-iodide springs. I have 
seen very beneficial results follow their use, more especially, of course, in 
the earlier phases of the disease. One case, in which I was consulted by 
Dr. Hammond of Preston, the greatest benefit was obtained ; the patient, 
who for some months had only gone out in a bath-chair, being after some 
time able to walk fairly well ; the already adducted fingers resuming their 
normal position and the nodosities greatly diminishing. I must, however, 
in justice, say that although other cases have profited from these waters 
prescribed by me, none other have obtained such very strongly marked 
benefit. 

I cannot say that I have found any benefit to accrue from blisters, 
iodine, or other derivative — but have thought that nightly compresses of 
solution of potash, or still better, of the Kreuznach Mutterlauge, has had a 
good effect, certainly relieving pain. The patient in this chronic stage 
should be encouraged to take a certain amount of exercise — motion retards 
the laming and stiffening progress of the disease. 



CHAPTEK Xni. 

INFLAMMATION AND DEGENERATION OP CARTILAGES. 

Most works on diseases of the joints contain a part devoted to maladies 
which have their especial seat in the cartilages ; and yet nothing can be 
more sure than that, of all the joint diseases which fall under the surgeon's 
notice, not one originates in the cartilage. It has been seen, that an inflam- 
matory action, commencing in the synovial membrane or in the bone, will 
spread to the cartilage and set up an ulceration of that structure ; it is also 
well known that in the dead-house and dissecting-room we frequently find 
breaches of continuity and tissue-changes in various articular cartilages 
which were accompanied by no symptom during life. The joints in which 
such conditions are found have been perfectly free from any pain or any 
diminution of mobility, at most a crepitating movement, and the neighbor- 
ing tissues have been perfectly untouched by any disease whatever. Thus 
we come to the inevitable conclusion, that disease confined to the cartilage 
gives rise to no symptoms ; and we must ask whether disease, which has 
commenced elsewhere and passes to the cartilage, may give any sign where- 
by we can tell whether or no the cartilage be diseased ? To answer this 
question fully it is necessary to enter somewhat deeply into the physiology 
and pathology of cartilage ; but as the subject has occupied some attention 
in each division of this work, it will be only necessary to revert to the points 
already treated, and the present chapter will rather be a resume than a full 
. exposition of the subject. 

The questions resolve themselves into these : Are there different sorts 
of ulceration of cartilage ; one accompanied, the other unaccompanied, by 
any symptom? If so, are either or both these ulcerations produced by 
some action of the tissue itself, or of some other tissue, absorbing the car- 
tilage as a passive material ? 

Sir B. Brodie has, throughout all the editions of his work on Diseases 
of the Joints, adhered to his original view of active changes in the cartilages ; 
in his earlier papers he ascribed these to the intervention of vessels ; and 
he has even in his fifth edition some difficulty in getting rid of the idea, 
since he affirms that " in persons who have not yet attained their full 
growth, vessels penetrate into the articular cartilage." Mr. Aston Key, 
however, in 1833, saw some reason to doubt the possibility of any vital ac- 
tions in cartilage, and attributed their absorption entirely to the "villous 
processes developed on the synovial membrane during inflammation of that 
structure." Sir B. Brodie, nevertheless, adhered to his original idea. In 
1843 M. Bichet, 1 of the H6pital Bon-Secours, added his testimony to the 
idea of cartilage being a dead, an almost inorganic, material. Dr. Ecker, 3 

1 Riohet : Sur les tumeurs blanches. Annales de chirurgie. 

! Ueber Abniitzung und Zerstorung der Gelenkknorpel. Archiv fiir physiologische 
Beflkunde, vol. u., p. 235. 



268 DISEASES OF THE JOINTS. 

in 1844, published the first observations upon the actions and conditions 
of cartilage-cells in disease. One of Mr. Goodsir's " Pathological and Sur- 
gical Observations," in 1845, also mentioned the growth and increase in the 
number and size of the cells. In 1848 Dr. Bedfern published a series of 
careful and minute observations " On the Abnormal Nutrition of Articular 
Cartilages," carrying further the researches of Ecker and Goodsir, and dis- 
closing many details which those authors had not mentioned. 1 Yet the 
idea that cartilage is truly a living structure, capable of vital action, pene- 
trated so slowly, that in 1853 M. Eichet, in a paper on white swelling, 2 in- 
sisted upon the inactivity of cartilage, and was at pains to prove that it is 
incapable of any independent action, saying, although he refers to Dr. Bed* 
fern's paper, " that the only direct manner of proving that cartilages are 
susceptible of inflammation would be to demonstrate vessels in their sub- 
stance itself." Mr. Birkett 3 censures the use of the word ulceration, and 
desires to substitute " disintegration." 

Mr. Bryant,' following too implicitly in this path, ascribed all the dis- 
eases of cartilage to atrophy ; degeneration and hypertrophy being only 
mentioned in order to throw doubt on the possibility of their occurrence. 

I believe myself to have been the first to have pointed out, that those 
diseases of cartilage which accompany the inflammation of other tissues in 
the joint are, in reality, also inflammation. 6 The whole view of the subject, 
and the arguments which irresistibly lead to this conclusion, have been al- 
ready detailed in several preceding chapters. Histologically, cartilage' be- 
longs to the connective tissues, and we have seen abundant evidence of the 
fact that their inflammation is accompanied by, or to a certain extent con- 
sists in, a rapid multiplication of the cells which form an essential part of 
their structure. Previous to and in 1860 I pointed out in the first edition 
of this work, that the cell-proliferation which causes those forms of cartilage- 
disintegration that accompany inflammatory joint disease, is itself inflam- 
mation ; that, in fact, the cartilages are, like the other articular structures, 
areolar, ligamentous, and osseous,' capable of inflammation. Nor do I 
hold that the discovery of emigrated leucocytes vitiates, though it may to 
a certain small extent modify this doctrine ; for it must be remembered 
that both Von Becklinghausen and Cohnheim never pushed their views to 
the length which some of their followers have reached, in ascribing all in- 
flammatory phenomena to the influence of " Wanderzellen." There are 
three roads by which such bodies could penetrate the cartilage : through 
the articular lamella, by the margin of the synovial membrane (structurally 
continuous with the cartilage), and by first mixing with the synovia. Of 
these roads the first is problematical. The second route is certainly open ; 
and I have seen, when the synovial membrane has been inflamed, bodies I 
conceive to be more or less altered leucocytes, infesting this border and 
slowly undergoing changes into fibre-cells. The third road is also feasible ; 
but I have always failed to find such bodies penetrating beyond the mere 
surface of the cartilage, unless where a false membrane or concretion had 

1 See my paper On the relation between Synovitis and Ulceration of Articular Car- 
tilages, Edinburgh Medical Journal, February, 1860. 

s Memoires de l'Academie Imperiale. tome xvii., 1853. 

3 Guy's Hospital Reports, second series, vol. vi., p. 237. 

* Diseases and Injuries of the Joints. 

6 See my paper On the Nutrition and Inflammation of Articular Cartilages, in Med.- 
Chir. Review, October, 1859. 

6 See my paper On Granulation, Beale's Archives, vol. ii.. No. 5. 

' See my paper On Osteitis, in Med.-Chir. Review, April, 1860; and Chap. XI. 



INFLAMMATION" AND DEGENERATION OF CARTILAGES. 269 

adhered or unless inflammatory pus (not mere surface pus, see p. 29) was 
in the cavity. In such circumstances the cartilage is milky ; its surface is 
soft, accepts readily and retains the impress of the nail, and lies loose, like 
a film partially detached, upon the deeper parts. Again, when breach of 
surface has taken place, leucocytes may perhaps readily find their way into 
the ulcer ; some of the smaller cell-forms are possibly emigration-bodies. 
But of this I am quite sure, that the chief work of cartilage-ulceration is 
effected not by Wanderzellen, but by the proliferation of cells belonging 
to the cartilage itself, which eat up or absorb the hyaline structure' as nutri- 
ment for their hyperplasia. 

Inflammatory diseases of the cartilage only occur when surrounding 
structures are inflamed. The reason that inflammation of cartilage does 
not form a primary joint disease is to be found in the insusceptibility of 
that material to mechanical or other irritation — an insusceptibility which 
constitutes its great value — and also in its sluggishness of action. Hence, 
many injuries or irritations may be insufficient to produce primary inflam- 
mation of cartilage, yet be amply intense enough to set up synovitis, which 
may secondarily cause those structures to become inflamed. Or, again, an 
injury may be sufficient to cause primary cartilaginous inflammation ; but 
it must, at the same time, of necessity be sufficient to produce either syno- 
vitis or ostitis, or both, and the actions of either tissue being so much more 
rapid than that of cartilage, we find these inflammations preceding the car- 
tilaginous disease. The question is not whether cartilage be susceptible 
of primary inflammation, but whether, under the circumstances in which it 
is placed, such disease ever presents itself to the practical surgeon. It can- 
not, probably, be directly proved that inflammatory ulcers of cartilages 
never take place unless some other part of the joint-apparatus be also dis- 
eased ; but we know that the symptoms of joint-inflammation become 
greatly aggravated when the cartilages begin to participate, hence this in- 
flammation is a painful and wearing disease ; but we never come across 
such symptoms unaccompanied, or rather unpreceded, by inflammation of 
other joint-structures. 

The inflammation may be, as we have already said, acute or chronic. 
It consists essentially in the rapid generation of cells from those primarily 
existing in the structure. When this generation is very quick, it absorbs 
the hyaline substance rapidly, and an ulcer, with clean-cut edges, is pro- 
duced ; when the action is chronic, the hyaline structure is first converted 
into fibres, which render the edge and bottom of the ulcer rough and un- 
even. The changes which the cells undergo have been described by Mr. 
Redfern, who has not, however, separated degenerative from inflammatory 
diseases. The first appearance in microscopic examination of the inflamed 
tissue, is an increase in the number of nuclei contained in the cells, and in 
the number of cells in the corpuscle — hence the increase of these bodies in 
size. In the most acute form of the disease the corpuscles are converted 
into large conglomerations of cells and nuclei, lying very close together, 
many of the cells containing two or more nuclei. In the most acute forms 
this growth is so rapid that it devours entirely the intercellular material, 
and thus an ulcer is left, with perfectly clean, smooth edges. 

The chronic inflammation differs from this by the more plastic character 
of its results. A large number of the cells formed do not simply become 
pus-cells, but, being produced by a slower action, have a more persistent 
character and a more perfect life. They change into fusiform and into 
fibre-cells, and thus the fibrillation of cartilage is, in such instances, not a 
mere mechanical splitting of. hyaline structure, but is also, in part, an ac- 



270 DISEASES OP THE JOINTS. 

tual production of fibres from cells — the action is almost identical with the 
physiological changes which in the embryo convert what formerly was car- 
tilage into synovial tissues ; but in the circumstances now Under review 
the process is morbid, and the material formed is a coarse sort of areolar 
tissue, or a fibro-cartilage (see Figs. 7 and 8). Much of this formation is 
not doomed to be persistent, but some of it goes on developing further, 
while the action increases in area, and at last some of it comes in contact 
with granulation from the synovial membrane, or from the bone (the arti- 
cular lamella having in places disappeared). The two parts thus in contact 
are engaged in identical processes, the transformation of fusiform cells into 
cell-fibres and areolar tissue ; they therefore unite, or rather grow together, 
so intimately that it is impossible to find the boundary between the two 
structures (p. 101). ' When a disease stops at this stage, we may find, upon 
subsequent examination, a partial and false anchylosis ; that is, there will 
be anchylosis in some parts, sound cartilage in others. Sometimes chronic 
ulcers, if small, leave behind simply a cicatrix, like a scar in any other tis- 
sue. These marks in cartilage are always the result of a very slow inflam- 
mation ; a more rapid action, instead of converting the cells, their progeny 
and the hyaline substance into fibre- and areolar-cells, causes them to dis- 
appear, leaving a breach of surface which is not filled up by any scar. 

When the primary attack is an ostitis, the cartilage undergoes the pro- 
cess both of degeneration and inflammation. In articular diseases thus 
-commencing it is to be remembered, that generally only one of the bones 
forming the joints is primarily affected ; moreover, it is seldom so exten- 
sively diseased that the whole surface, whereon the cartilage rests, under- 
goes morbid action at the same time. Now, the first effect of an ostitis 
upon the cartilage is, in most instances, a cessation of its supply of nutri- 
ment ; hence detachment, with its articular lamella, from the inflamed por- 
tion of the bone (see Fig. 47). Around the spots where such degeneration 
•takes place, the cartilage will not thus be killed, as it were, by starvation, 
but either remains normal or will become inflamed and ulcerated. The 
cartilages covering the bone, which still remains normal, will, when the 
■other joint-textures become inflamed, participate in the inflammation, just 
as they do in a synovitis. Thus, in articular diseases, commencing in one 
•of the bones, there are two sorts of action going on in the cartilages — in- 
flammation and exfoliation. Sometimes even in cases originally synovitic 
portions of cartilage may be thus shed. This occurs when the articular 
lamella has been in some points perforated, whence cancellar hyperemia has 
ispread, and undermined a portion of cartilage previously healthy. The 
cartilage which has suffered degeneration, and which lies over the focus oi 
inflammation, is detached with the articular lamella by the ostitis itself, and 
is frequently pushed by a collection of pus, or a growth of granulations, 
into the joint-cavity, in which it is found lying loose and fatty, its formerlj 
attached surface feeling gritty like sand-paper, from the adherence of the 
.more or less broken-down articular lamella. 

But ulcerations of, i.e., breaches of continuity in, cartilage occur when 
the parts around are perfectly healthy. The existence of these lesions is 
not suspected during life ; they are found in the dead subject, whose ar- 
ticular functions had been perfect. Such ulcers look to the naked eye more 
fibrous, rough, and are generally softer than those already described 
isometimes the cartilage is converted into a set of parallel fibres, close to- 

1 It was this condition which led Mr. Aston Key to conclude on the destruction oi 
(cartilages by growths from synovial membrane. 



INFLAMMATION AND DEGENERATION OE CARTILAGES. 271 

gether, and standing from the bone surface as the pile of velvet from the 
woof ; and often that part of the cartilage is yellow. If sections' of this 
material be examined microscopically, the corpuscles will be found increased 
in size, and the contained cells are also larger ; but they are not increased 
in number. Those corpuscles which contained two, three, or four cells 
near the attached surface, still continue, on approaching the outer edge, to 
possess only an equal number of cells. The nuclei do not multiply ; on the 
other hand, they become obscured by an accumulation of minute globules 
of oil around them, between the cell-wall and the nucleus ; in a further 
advanced stage, and nearer the free surface, the corpuscle itself gets filled 
with the oil, which lies around the cells, while the hyaline substance is 
crowded with and rendered opaque with oil-globules. The fibrification of 
the hyaline portion commences by the appearance of thin, faint strise ; in 
some instances there may be seen between these a row of oil-globules, and 
the strife become numerous and more open, until the substance is split 
into fibres. 

This fatty degeneration is a passive disease, and consists simply in the 
fact that the cartilage-cells have imbibed material which unfits them for 
their nutrient function. There is also another form of cartilaginous de- 
generation — the granular ; it has the same effect upon the hyaline substance 
of splitting it into fibres. Microscopic examination shows that the corpus- 
cles, when thus affected, become minutely spotted with a substance more 
opaque than the surrounding material ; they, at the same time, become 
enlarged, but very shortly afterward shrivel, each corpuscle forming a thin 
transverse scale long before it comes to the free edge ; these lines, or scales, 
appear divided, as though by the old cell-walls, but the usual aspect of the 
cell and corpuscle is lost. 

I consider that the fatty degeneration of cartilage is similar to that de- 
generate state of the cornea which Mr. Canton has shown to be the essence 
of arcus senilis, while the granular is comparable to the atheromatous con- 
dition of arteries. 

In neither of these cases do the nuclei and cells multiply ; they simply 
absorb a morbid material and lose their nutrient power, hence the action 
in question is a passive one — a mere degeneration. The function of artic- 
ular cartilage is so passive, and is spread over so large a surface, that we 
have no means of ascertaining when these degenerative diseases are taking 
place over a small extent of the tissue ; and, being but passive changes, 
they are not accompanied by any hyperaemia, nor by any pain. The ulcer- 
ation, then, of cartilages may be divided into inflammatory and degenera- 
tive, and these latter again must be subdivided. The changes whereon 
degeneration depends are situated in the cell, and therefore we must class 
them according to conditions of that body ; hence the term fibrous degen- 
eration is false, and the more so as fibrification of the hyaline substance 
accompanies every morbid change of cartilage. We may therefore divide 
degenerative diseases into fatty and granular, and as these are mere passive 
changes, occurring in a structure without sensibility, so they do not give 
rise to any symptoms. 

Another form of malady resulting from deposit in the cartilage of a 
morbid material, viz., urate 6f soda, appears scarcely to belong to the de- 
generative class, although it ends in degeneration. The chalk is deposited 
actually in the cartilage, i.e., in the hyaline substance around the corpuscle; 
but the extreme opacity of the material renders it extremely difficult to 
trace the connection between it and the containing tissue. It soon splits 
the cartilage and lies among the fibres, which, if the deposit be in any 






272 DISEASES OP THE JOINTS. 

great quantity, almost disappear, and the tissue is converted into a layer 
of chalk-stone, held together by scattered fibres. Sometimes this deposit, 
or other cause, sets up inflammation, which causes the cartilage to yield 
more completely, and the urate is thrown off into the joint, sometimes en 
masse, sometimes mingled with the pus, or synovia, to which, being held 
in suspension, it gives a peculiar milky color and gritty feel 

A peculiar change of structure has been much studied by my friend 
Dr. Reyher of Dorpat. I regretfully refer to his admirable work ' for de- 
tails, being obliged by the limits of my space to renounce quoting his con- 
clusions fully. He experimented by placing one limb of a number of dogs 
in plastdi-of-Paris bandages for a variable number of weeks ; the result 
being that those parts of the cartilage which were out of contact underwent 
gradual transformation into areolar tissue (Bindegewebe), with develop- 
ment of " epithelioid " cells. This transformation is the same as that 
which I long ago described as taking place under the synovial proces- 
ses, and is never combined with either fatty, granular, or caseous degener- 
ation. 

At p. 182 I mentioned the singular fact that pieces of articular cartilage 
may be chipped out from the rest and he loose in the articular cavity, form- 
ing one species of loose body. Such rending away of a fragment from a 
previously healthy cartilage is evidently impossible. The process whereby 
the detachment is determined was described by Mr. Teale 2 as an effect of 
traumatism, producing a necrosis of the cartilage with the underlying layer 
of bone. Sir James Paget's subsequent nomenclature, " quiet necrosis," 
marks its noninflammatory character. 

The growth of a cartilaginous tumor from healthy cartilage, an ecchon- 
drosis (by this term an analogy with exostosis is indicated), is a very rare 
event, concerning whose occurrence I am sceptical. 

In the examination of certain joint diseases, viz., chronic rheumatic syno- 
vitis and arthritis deformans, the cartilages will be found tp have lost their 
opalescent appearance, to have become abnormally transparent, of a pinkish 
brown color, and to be very much thinner than natural. They have in such 
cases an even surface, except rarely in a few small spots where they may be 
ulcerated, the ulcers smooth or nearly smooth ; very frequently a piece of 
eburhated bone will be found on the same plane as the cartilaginous sur- 
face. I believe this condition to be a slow form of inflammation, tending, 
like other processes of rheumatic origin, to the completion of all the pails 
involved. The attenuation, I believe, takes place, not from the free but 
from the attached surface, by encroachment of bone upon the cartilage, and 
this opinion is much strengthened by the fact, that there seems to be a 
solid case of bone thicker than usual between the osseous cancelli and the 
cartilage ; moreover, the articular lamella gradually assumes more and 
more the structure of ordinary bone. 

It is certain that cartilage being endowed with nutrient power may be 
capable of both hypertrophy and atrophy, but practically we do not come 
across such diseases. In young subjects the cartilage may be found exces- 
sively thick, but I have always attributed this to delayed ossification of the 
epiphysis. In adults the cartilages may be found slightly thickened, but 
they are then likewise sodden and soft, and their increase probably results 



1 Ueber die Veriinderungen der Gelenke bei dauernder Euhe. Zeitschrift der Chi- 
rurgie, iii., p. 189. 

* Medico-Chirurg. Transactions, vol. xxxix. 



INFLAMMATION AND DEGENERATION OP CARTILAGES. 2 i 3 

from mere passive imbibition of fluid. Still, as above stated, the possibil- 
ity of simple hypertrophy cannot be denied to a tissue capable of both nu- 
trition and inflammation. 

Atrophy of cartilage, as described by some authors, that is, considerable 
decrease in its normal thickness, is due, I believe, to encroachment of 
bone upon its deep surface, as just described. The granular and fatty 
degeneration is a result of ill-nutrition, and the only undoubted form of an 
atrophic condition. 
18 



CHAPTER XIV. 

HIP-JOINT DISEASE. 

Pathology. — It may not be in accordance with strict logical arrangement 
"that one particular joint should he singled out for a special chapter ; but it 
•will, I believe, tend to make this book more valuable, if the diagnostic signs 
of hip-disease be separately discussed. By means of this articulation, the 
strongest limb in the body is fastened to the trunk itself ; it lies so deep, 
that at no part can we put our fingers immediately upon or over the syno- 
vial membrane, as in every other important joint ; and we cannot, therefore, 
detect fluctuation, changes of shape, or of size, with anything like the readi- 
ness with which we can find the like alterations in other and more su- 
perficial joints. For example', an inflammatory affection of the knee is often 
revealed by the swelling, before any pain shall have called the patient's at- 
tention to the part ; the changes of shape, size, etc., are perfectly distin- 
guishable, and the failure of mobility is easily detected. But the round, 
massive form of the parts about the hip, the difficulty, or rather impossi- 
bility, of fixing the pelvis with the hand, the projection of the trochanter, 
and the bend of the neck of the femur, rendering the true radius of motion 
very short, the mode in which the whole head of the bone is impacted in 
the socket, and many other circumstances, throw great obstacles in the way 
of a diagnosis, concerning merely the presence or absence of disease at this 
articulation. 

The rarity of opportunities for obtaining specimens of recent disease 
produces great diversity of view as to the particular structure in which the 
malady may begin. This commencement has been accredited to the Haver- 
sian gland, to the ligamentum teres, and to the cartilages as well as to the 
synovial membrane and bone. The symptoms, viz., lengthening, shorten- 
ing, pain at the knee, etc., have been attributed to almost as many causes as 
there have been authors to assign them, and thus the whole subject is still 
-greatly involved, and, in not a few points, obscure. 

First, as to the structure in which disease of the hip-joint may com- 
mence. There can be no doubt that it may begin either in the synovial 
membrane or in the bone, like other joint diseases ; there is neither any 
proof nor any reason to suppose that, unlike other joint diseases, it may 
start from the ligaments or cartilages. "Who ever heard of a knee-joint 
disease beginning in the crucial ligaments ? Who has not heard of a hip- 
disease beginning in the round one ? The reason of this preference for, I 
had almost said superstition about, the ligamentum teres lies in the fact 
that it carries the blood-vessels, which convey nutriment to the epiphysal 
head ; therefore an epiphysitis, a very common event, must of necessity 
produce hyperemia of the vessels in the ligament, which is soon followed 
by inflammation and softening of the whole structure. One must not there- 
fore accept, as an instance of primary affection of this ligament, any case of 
inflammation or ulceration, unless section of the bone have been made and 
that structure have been found free of disease ; especially as in no case of 



HIP-JOINT DISEASE. 



275 




Pig. 48. — Upper end 
of femur ; still-born child. 



ostitis about the epiphysis have I ever found the round ligament other than 
entirely absorbed, thinned and inflamed, or ulcerated and hanging in 
shreds. 1 Thus we come back to the two tissues — synovial membrane and 
bone —whose morbid affections are, as we have seen, 
the cause of all joint disease. The synovial membrane, 
however, of the hip, unlike that of the knee, is particu- 
larly well protected against external violence and out- 
ward cold ; the bones are, on the contrary, in a condi- 
tion peculiarly apt to pass from health to disease. 

The anatomy of this articulation in early life is 
somewhat peculiar. The acetabulum is not, as in adults, 
hollowed out of a single bone, but is divided into three 
parts by as many lines of cartilage, which, radiating 
from near the centre of the cavity, like the limbs of a 
letter Y, give that name to the junction. Along both 
margins of each line enlargement by growth takes 
place ; therefore, in six parts of the cavity within the 
synovial sac, great plastic activity, together with hy- 
peremia, is continually going on. 

The upper extremity of the femur of the newly born 
babe is very different in form from the fully developed 
bone ; the.head is large in proportion to the trochanters and shaft, the neck 
being quite undeveloped, so that the former seems sessile on the latter por- 
tion. Some time during the first year of life a bony nucleus appears in the 
upper part of the head, and during the fourth year an apophysal centre for 

the great trochanter. The small trochan- 
ter, whose ossification is much later, need 
not interest us here ; but the peculiarities 
of relationship between the epiphysal head 
and the rest of the bone are very important. 
The subjoined cut, representing the section 
of a bone before union of its various parts 
has taken place, shows that the epiphysis 
does not form by any means the whole up- 
per extremity of the femur, but that all the 
lower and outer portion of the head and 
all the neck of the bone are derived from the 
diaphysal centre. Now, if we compare the 
upper femoral end of a newly born child 
(Fig. 43) with that of a boy in his sixteenth 
year (Fig. 44), if we consider the place 
where the synovial membrane (represented 
by a dotted line) is attached, we see at once 
that the whole growth of the head takes 
place within the joint-cavity ; and not only 
so, but that all the neck — viz., more than an 
inch in length of a large bone — is formed en- 
tirely within the synovial membrane, which, as we see, encloses not merely 
the epiphysis, but also a large portion of the rapidly growing diaphysis. 

1 Mr. Aston Key, Med.-Chir. Trans., vol. xvii., p. 230, gave the weight of his au- 
thority to this view. Mr. Holmes, Surgical Diseases of Childhood, p. 253, adneres, 
somewhat dubitating, to the same idea. The case he quotes and the plate do not, 
for reasons given in the text, support him. The case related by Martin and Collineau, 
De la Coxalgie, pp. 142, 143, is, to my mind, a typical example of osteo-myelitis. 




Fig. 44.— Section of upper end of f emar : 
boy aged sixteen. The diaphysis is left 
light ; the additions are in tone, a, shaft, 
neck, and diaphysal head, e, epiphysal 
head, c, d, large and small trochanters. 
The dotted line marks the synovial insertion 
(diagrammatic). 



276 DISEASES OF THE JOINTS. 

let us contrast this condition with other large joints, as the knee. Here 
"both the epiphysal junctions, save the anterior extremity of the femoral one, 
lie outside the joint ; we see at once that hypersemia, even disease about 
these parts, may persist for a long time without affecting the joint itself, 
because there is no immediate connection or communication between the 
one and the other. At the shoulder the inner portion of the epiphysal junc- 
tion lies within the synovial sac ; but, in the absence of a real neck to the 
humerus, how weak in comparison to that at the femur is the formative 
energy ! At the hip, both pelvic and femoral growth He entirely within the 
joint-sac ; that growth is most rapid, aad any over- action, any inflammatory 
or other morbid condition, at this place is at once reflected as a joint dis- 
ease. To my mind there is no doubt whatever that nearly all cases of 
chronic infantile hip-joint disease originate in the bone, and more espe- 
cially about the pelvic or epiphysal junctions. 

Case LXVII. — John C, aged five, was admitted under my care into 
Charing Cross Hospital, April 19, 1879, with hip disease. It appeared that 
limping had first been observed three weeks before that date, but the child 
had been ailing and complaining of pain about the limb a week or ten days 
previously. The child appeared very ill, weak and apathetic, and fatigued 

in the daytime, wakeful and 
starting at night. .It was very 
difficult to get the child to walk 
even a step ; he would not put 
weight on the limb. 

On the 4th of May cerebral 
symptoms set in, and on the 
10th he died of tubercular men- 
ingitis, as the symptoms and 
post-mortem appearances show- 
ed. Fig. 45 is a representation 
Fia. 45.— Femoral hip disease. of parts at the hip, in the po- 

sition necessary to show the os- 
seous caries ; what remains of the round ligament can barely be seen ; it 
was very thin, soft and shreddy ; red, and infiltrated with a blood-stained 
serum. The epiphysal and diaphysal head of the bone, with a portion of the 
neck, was at its lower part quite carious; the excavation shown in the figure 
was, when fresh, filled up with thick pus, mingled with bony detritus and 
soft granulation-tissue. The cartilage was intact, though thinned, except 
around the carious cavity, where it had in great part disappeared ; it was 
detached from the bone for a considerable distance round the margins of 
that excavation. 

Case LX"Vlll. — James L., aged four, came under my care into Charing 
Cross Hospital, January 13, 1879, in the first stage of hip-disease on the 
right side. He had the third stage of phimosis. There was no lengthen- 
ing, but it was difficult to get him to walk ; when he did so, the step was 
irregular. The right foot was barely advanced, but brought slowly to the 
level of the left; then the other took a rapid step, during which the body 
was thrown over to the right. The boy had an abscess, still deep, on the 
top of the thigh, outside the origin of the rectus. 

For a long time the boy was kept in bed ; the abscess gradually in- 
creased and came forward ; the thigh became considerably lengthened. In 
the middle of May, 1879, the abscess was close to the skin, and was opened 
and dressed antiseptically till the beginning of June. At that period marked 




HIP-JOINT DISEASE. 277 

shortening of the limb set in, and discharge from the abscess greatly in- 
creased. I now enlarged the opening and passed my finger into the cavity ; 
it led by a rather narrow channel down to the lower aspect of the neck close 
to the head. Here osseous grating under the finger revealed through the 
capsule a carious condition of bone. 

June 26th. — I excised the joint, removed the head and great trochanter ; 
found the truncated extremity of the femur soft and becoming carious ; 
stripped off the periosteum and took away an additional piece, which I 
afterward found measured just over three-quarters of an inch. At the 
upper posterior part of the acetabulum was a spot the size of a four-penny- 
piece, bare of cartilage, and the bone, being very soft, was gouged. 

I have the portion of femur now before me. At the lower part of the 
epiphysal and diaphysal junction is a small hole in the bone, but the ulcer- 
ation extended the whole length of the under-surface of the neck, with in- 
flammatory softening nearly an inch down the inner aspect of the femur. 
The cartilage of incrustation was detached for a considerable distance around 
the opening, but was normally thick. At the upper and back aspect of the 
head was an oval spot, as large as a silver threepence, of cartilage-ulceration, 
laying bare the bone ; a narrow margin of the cartilage around this ulcer 
was thinned, so that near the edge it was transparent.' The ligamentum 
teres had entirely disappeared, save a few shreds in the digital fossa of the 
femur. On section, the small hole mentioned above was found to lead to 
an excavation occupying the lower two-thirds of the epiphysal line and ex- 
tending some way into the epiphysal head — the hollow contained pus. 

I have several other cases of coxitis, were it desirable to quote more 
largely, commencing at the particular part above described, namely at the 
lowest point of the line of junction. In all of them the ligamentum teres 
shows various morbid conditions, from entire destruction to mere hyperse- 
mia and engorgement ; yet none would say, I imagine, that the disease com- 
menced at that part. 

While wishing to lay some stress upon the frequency with which femoral 
hip-disease begins about the epiphysal line, and in preference about its 
lower part, it must be understood that the 
malady also frequently commences at or 
about the osseous nucleus, or, if this have 
taken entirely the place of the primordial 
cartilage, anywhere in the epiphysal head. 
I need not here describe articular ostitis, 
as the subject has been already amply treat- 
ed at pp. 197-238, but would point out that 
one reason for the frequency of this condi- 
tion at the hip is the peculiar, one might al- 
most say inadequate, blood-supply through 
the vessels of the round ligament. The 
epiphysis appears not merely to wear away p. g 46 ,_ Femora i hip ai6e a S e commeuc- 
at the surface, but to shrivel, perhaps rather ing in epiphysis itself. 
to cease to grow. The annexed plate is 

from an excised upper part of the femur. There was no vestige of round 
ligament, the cartilage was absent, the bone-cancelli exposed and granula- 




' I would call attention to the beautiful distinction which Nature here showed be- 
tween destruction, or rather detachment, of cartilage from ostitis and the ulceration 
produced by pressure, so clearly seen at the upper part, and which was evidently 
recent. 



278 



DISEASES OF THE JOINTS. 



ting, the epiphysal line sound, but all the epiphysis soft (osteo-malacia) ; the 
girl did well after the bone had been resected. 

In former chapters the fact has been accentuated that while in synovial 
disease the cartilages begin to ulcerate on their free surface, they are in 
ostitic joint disease generally first invaded from their deep surface, being 
detached with their articular lamella throughout a larger or smaller extent, 
and then degenerate sometimes so slowly, that even after months of dis- 
ease such loosened pieces may be found looking nearly normal among the 
granulations. l This occurs more frequently in exsections of the hip than 
of any other joint. The size of the detached piece depends on the extent 

of bone-surface implicated in 
the inflammation. An ostitis 
attacking the whole epiphysal 
head may cause shedding of 
the whole cartilage, as in the 
annexed plate. I was obliged 
to resect the head of this fe- 
mur on account of an acute dis- 
ease which threatened life, and 
found the whole cartilage de- 
tached, save from the diaphysal 
part of the head, where it was 
still adherent. 

Acetabular hip-disease is, 
though rather less common 
than the femoral, a sufficiently 
frequent affection to require 
careful study. The annexed 
plate is from a lad aged twelve, 
who was treated by me in 
Charing Cross Hospital while 
the first few chapters of this 
work were already in type. Ow- 
ing to objections on the part of 
his mother, no operation was 
performed. "While she was still 
endeavoring to make up her 
mind, brain-symptoms super- 
vened, and he died rapidly of 
tubercular meningitis in the early part of June. I was fortunately able, 
with the assistance of Mr. Whitehead, to secure the parts. The femur and 
its cartilage were sound, with the exception of the point at the top and back 
of the head, which always ulcerates from the effect of pressure (p. 280). The 
cartilaginous circumference of the acetabulum was also sound, except at the 
point corresponding to the femoral erosion. The cavity was full of grumous, 
. flocculent pus of a pink color (slightly blood-stained). At the bottom of the 
cavity, where the different limbs of the Y-cartilage join, was a ragged hole, 
somewhat triangular in shape, which led into an abscess within the pelvis. 
The intra-pelvic abscess, whose wall was formed by the obturator fascia, both 
dilated and thickened, was as large as two-thirds of a duck's egg, the larger 
end being placed so that it projected inward and a little forward from the 







Fig. 47.— Shedding of cartilage in subacute ostitis. 



1 I must refer to p. 103 for the explanation of an occasional similar find, even in 
synovial disease. 



HIP-JOINT DISEASE. 



279 



inner acetabular wall. It filled, therefore, a large space in the true pelvis, 
and, merging over or covering the ilio-pectineal line, occupied a certain 
place in the lower part of the iliac fossa. This is the most instructive speci- 
men that I have seen of the especial form of disease in question ; but other 
instances and conditions, found during excisions, have long ago made me 
aware that such malady exists, and clinical studies have taught me how to 
detect it during life. 1 

Diseases of the hip may also begin in the synovial membrane, but such 
mode of commencement is less common in this than at any other large 
joint. I have seen several undoubted cases of synovial hip disease, gen- 
erally traumatic or arising from over-fatigue, m boys between the ages of 
nine and fifteen. A careful study of the symptoms will always reveal their* 




Fig. 48.— Acetabular hip-disease : intra-pelvic abscess. 

nature in the earliest phases ; but diagnosis becomes more complicated and 
difficult, as in later stages the malady implicates other structures.''' 

Hip disease sets up a series of phenomena, which varies somewhat ac- 
cording to the mode of commencement ; common to all is this, that the 
disease is accompanied by contractions of the muscles passing between the 
pelvis and femur — such contractions produce many of the most evident 
and most discussed symptoms of the disease. But at present we have 
nothing to do with symptoms, we are simply concerned to note the effects 
of these muscular acts upon the structures of the joint. The muscles in 
question — passing, some horizontally outward to the upper end of the bone, 
some almost perpendicularly downward to the lower parts of the limb — 
must and do, when in a state of abnormal contraction, cause the head of 



' For the mode of making this examination, see p. 302. 

8 1 of course exclude from this view cases connected with exanthematous or enteric 
fever and with hysteria. 



280 DISEASES OF THE JOINTS. 

the femur to press -with unusual force against the upper and inner surface 
of the acetabulum, while counter-pressure is exerted upon the upper, inner, 
and back surface of that globe. The result is that in all cases, whether the 
disease be synovial, pelvic, or epiphysal, these particular portions and 
aspects of the articular cartilages become ulcerated. Hence, if in patho- 
logical examinations we meet with such erosion, we must not at once ac- 
cept it as the origin and root of the disease ; it is a mere pressure-effect, 
what the Germans call a " decubitus," using, as they do, the same word for 
a bed-sore ; it is nearly, if not quite, always secondary ; not the disease itself 
nor its cause, but the result of disease which generally has begun else- 
where. 

" To prove this position we have only to look at pathological museums ; 
we shall find a few specimens in which the action is distributed over the 
whole joint-surface ; a very few indeed in which the erosion has chiefly at- 
tacked the lower posterior or anterior part of the acetabulum and femur ; 
but in a proportion of cases so large as to render the above examples mere 
exceptions, the upper lip of the cotyloid cavity and the corresponding part 
of the caput femoris are ulcerating, while all the rest of the bone may be 
untouched. Such constancy of action can only be accounted for by the 
fact that abnormal muscular contraction produces pressure, and thereby 
ulcerative absorption of these parts. . The annexed figure, from Mr. How- 
ship's collection in the Charing Cross Hospital Museum, is not taken from 
a specimen particularly chosen to prove these circumstances ; in fact, it 
presents an unusual amount of action at the lower part of the acetabulum, 
evidently produced by the gravitation of pus. Let it be observed how the 
cavity of the acetabulum has been prolonged about an inch upward ; how 
the head of the femur has been altered in form ; how, also, in the position 
which in life they last assumed, the two fit accurately together, and how 
the track left behind became narrower as the caput femoris wasted. It 
is plain from this mere physical evidence that the head of the femur was 
used almost like a copper-plater's graver, to furrow the cotyloid cavity up- 
ward on the ilium, and has been almost worn out in the process. It has 
been held tightly to the floor of the cavity by the pyriform, obturators, 
and other capsular muscles, while it was forced upward by those which 
pass directly downward. The acetabulum is thus made to travel inward 
as well as upward, whereby an opening through the floor of the cavity 
into the pelvis is not unfrequently produced, as shown by the figure. I 
say, that such evident yielding to the pressure upward is not an excep- 
tional case, but is the rule : that when we find a hip-joint ulcerating in 
any other way and position, it is that some circumstance has caused a 
primary ostitis in that particular spot. It must also be remarked that 
as the head of the femur travels upward, producing, in that part against 
which it presses so abnormally, ulcerative absorption, it causes beyond 
that point an osteophytic growth of bone, forming a rough lip to the new 
cavity (according to the law of increased growth and induration beyond 
the focus of a suppurative inflammation). 

We now go on to consider the causes of certain phenomena, firstly of 
that one which is known by the name of pain at the knee. It often has and 
doubtless will again mislead diagnosis ; because, though in some cases it is 
not a prominent symptom, it is in others very marked and distressing, be- 
fore there is any disease at the synovial and ligamentous apparatus of the 
hip. It would lead us very far to give all the different solutions, right or 
wrong, which have been attempted, yet it is only proper that some should 
be quoted. Sir C. Bell attributed this pain to irritation of the obturator 



HIP-JOINT DISEASE. 



281 



nerve. Sir B. Brodie appears to entertain a similar opinion. 1 Coulson, to 
continuity of the inflammation along the aponeurosis of the rectus muscle. 
Richet conceived it to be due to propagation of the inflammation along the 
medullary canal to the lower end of the bone. Bonnet attributed it in many 
instances to malposition, which caused a constant strain on the ligaments 




Fig. 49.— Diseased acetabulum and head of femur. 

and muscles of the knee. Stromeyer, to spasm of the psoas and iliacus in- 
ternus. Walther and Fricke, to sympathy between the two ends of the 
bone. 

If we eliminate from these hypotheses those which are merely unsup- 
ported speculations, we leave only two tenable views, viz., irritation of 
nerve-trunks passing close to or supplying both joints, and sympathy be- 
tween the two ends of the bone. The nervous trunks which fulfil the above 
conditions are three : the sciatic, anterior crural, and obturator. The first 

■Op. eifc, p. 123. 



L 



282 DISEASES OP THE JOINTS. 

of these sends a twig to the hip, and three, sometimes two, small branches 
to the knee. It is doubtful whether this nerve has anything to do with the 
phenomenon in question, since the branches are supplied to points not in- 
volved in the knee-pain. 

The anterior crural occasionally supplies a branch to the hip, but it lies 
in close contiguity to that joint and sends several branches to the knee. 1 
A case related by Sir B. Brodie, which bears on this subject, should not be 
overlooked. " A man was admitted into St. George's Hospital, under the 
care of Sir Everard Home, complaining of pain in the knee, and of nothing 
else. On inquiry into his case, however, it was found that he also labored 
under Femoral aneurism. Sir E. Home applied a ligature above the tumor, 
which immediately diminished in size, the pain in the knee subsiding at the 
same time. The patient died afterward of venous inflammation, consequent 
upon the operation ; and on examining the limb I found that some branches 
of the crural nerve lay on the surface of the tumor, which terminated in the 
exact spot to which the pain had been referred, and this at once explained 
the origin of the pain, and the subsiding of it on the tumor becoming re- 
duced in size after ligature of the artery." * 

If pressure produced by an aneurism may cause pain at the knee, so it 
is probable that the pressure of a swollen hip-joint upon the same nerve may 
have a like effect. 

The nerve, however, whose influence has always, with justice, been con- 
sidered greatest, is* the obturator. The supply to both hip and knee, the 
place of distribution at the latter joint, the muscular phenomena to be con- 
sidered in the sequel, all point to the probability that this nerve is, of all the 
three, that one whose irritation principally causes knee-pain — that is to say, 
one of the sorts of knee-pain. 

Another causation is doubtless to be found in the propagation, not as 
Bichet thought of inflammation, but of morbid sensations along the bone, 
or, to state it more correctly, the tendency of all painful sensations of bone 
to be referred to its lower end. This is often marked when a part of the 
shaft is inflamed or necrosed, but more strongly so when the proximal end 
is involved. One important fact may be here quoted — " All these sympa- 
thetic pains have this peculiarity, that they never pass along the nerves up- 
ward, that is toward their origin, and that they are never increased by out- 
ward pressure, .and this latter circumstance should always produce suspicion 
of a distant origin of the malady. Lastly, I must remark that these pains 
usually follow the course of the nerve lying close to the disease ; but that 
there are cases in which they are transmitted along the medulla, or along 
the periosteum of the bone to its end. Thus I have now under my care 
an unfortunate boy suffering from caries and suppuration of the hip-joint, 
in consequence of which the caput femorisis dislocated upon the ilium ; 
has penetrated, by ulceration, through the soft parts, and lies bare, merely 
covered by delicate granulations. "When I press with my finger upon this 
denuded head of the bone, the patient does not complain of pain at that 
spot, but, by an involuntary movement, grasps the condyles of the femur, 
and complains of very intense pain in them, although pressure upon these 

1 I have twice in the course of dissection found a small twig, from the external cir- 
cumflex branch of the nerve, pass into the capsule of the hip-joint — the same branch 
sends down a long, sroajl twig to the outer side of the knee, another ramus comes from 
the vastus internus nerve and goes to the inner ride of the knee. The patellar plexus, 
between branches of this and of the obturator nerve, may also have its influence. 

5 Op. cit, fifth edition, p. 281. 



HIP- JOINT DISEASE. 283 

condyles themselves is entirely painless." ' Having these observations of 
Wedemeyers in my mind, I had a few years ago the good fortune to 
detect the cause of a violent knee-pain in an abscess a little above the 
middle of the femur. The peculiar pain at the knee produced by pressure 
on a dislocated and inflamed caput femoris I have been able in two cases 
to verify. 

Of these two sorts of knee-pain, one is situated in a nerve, therefore is 
connected with inflamed synovial membrane of the hip ; the other pain, 
with ostitis of the head of the femur. Both may be somewhat early in ref- 
erence to other symptoms ; but the latter form, if hip disease commences 
in the thigh-bone, is very early ; it occasionally antecedes all other symptoms, 
save perhaps a slight limp. 

Starting-pains result, as we have seen in other chapters, from inflam- 
matory conditions of parts beneath or near to the articular lamella ; thus 
in ostitis they are relatively earlier than in synovitis, and in this way the 
interrelation between starting- and knee-pains become clear. 

Fixity of the thigh upon the pelvis occurs very early in hip disease ; it 
arises from contraction of muscles, more especially of those immediately 
surrounding the capsule. The thigh is thus fixed at certain angles, antero- 
posterior and lateral with the pelvis ; fixed, that is to say, as far as any one 
examination is concerned ; yet the posture gradually increases : firstly flexion 
and abduction become considerably, but by imperceptible degrees, more 
marked ; then arrives a time when a more or less sudden change takes 
place ; flexion remains, or indeed increases, but abduction is changed into 
adduction. As to the cause of this, nothing distinct is known. The ex- 
periments of Bonnet, Dittel, and others, showing that distention of the cap- 
sule produces at this joint abduction, does not appear to me to throw much 
light upon the matter. 

Abduction produces a certain peculiarity of form which marks off the 
second from the first stage of the disease, and which is termed lengthening. 
Abduction of the thigh on the pelvis may be estimated by eye or otherwise, 
if the surgeon, standing well over the patient lying supine on the couch, 
places the tip of the index fingers on each anterior superior spine, thus 
marking the extremities of a line supposed to be drawn between those 
points,; the other 1 line, that of the thigh, is distinct, running from the cen- 
tre of the patella to one or the other finger-tip. If these lines meet at angles 
of about 90°, and are equal on both sides, there is neither abduction nor ad- 
duction ; the angle, whatever it be, will be maintained by the very postu- 
late of the case — namely, fixity of the thigh on the pelvis. It remains for 
us to see how abduction, the obtuse angle, produces lengthening ; adduc- 
tion, the acute angle, shortening. 

Lengthening of the leg, such as occurs in an early stage of hip disease, 
is the effect of two conditions ; abduction of the thigh, and the necessity of 
maintaining a certain parallelism of the limbs while the angle of abduction 
remains the same. With the cause of abduction we have for the present 
nothing to do, but merely with its effect. Fig. 50 shows the pelvis with 
the right thigh abducted at a certain angle, a, b, c. It is evident that no 
child could stand for more than a few seconds in the position necessitated 
by such posture of the liinb — the one foot in the air, all the weight and 
balance entrusted to the other limb ; nor could a person long maintain, 
unless compelled by splints, such an attitude in b